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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. — <br /> �4 APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE , <br /> LIQUID WASTE <br /> Application is hereby made to car on business in the jurisdictional area of the Sa oaquin Local Health District <br /> H Business Name (D ) ,�. Z--42 G� _ Address ��r. 23 /V!r /-J7�iQ- <br /> 1 { <br /> C Owner_ ��,� 6l� � "~2 - _i Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> 5!� <br /> 4 Business Telephone No. t? f _ Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) 4•.L. vLGy= _ Title �&.RY-�lt�-�L- Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) f <br /> Serial No. 1 CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address { <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 11 ' <br /> No. of Vehicles Stored <br /> No. of Chemical To letsored t <br /> 3. ❑ PERCOLATION TEST } <br /> R.S. or R.C.E. Name ; Z R,S..or.R.C.E. No. <br /> Test Location Test Date/T"ime p <br /> 4. ❑ SANITATION PERMIT .; <br /> Job Address/Location jeU0t <br /> Owyler Address <br /> VSEPTIC�ANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT ! <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ,z. _ _ � ❑ REPAIR ❑ OTHER t <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 � <br /> Type Construction Disposal Site I # <br /> Na. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June-30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served t iT i <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑' Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i { t <br /> hereby certify that I have prepared this application and that the work will'be.donein~accordance With San Joaquin County <br /> ordinances, state laws, and rules and4 a atio of the San Joaquin Local Health`District`'. i <br /> APPLICANT'S SIGNATURE Z59 b�f <br /> FOR DEPARTMENT USE ONLY =� <br /> A.. <br /> Fee Is Due: ❑ ANNUALLY El PER UNIT 11 PER SITE ❑ EACH ❑ January 1 &Received By January 31 July i &Received By July 31 <br /> REMIT <br /> t BASE '' EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED f <br /> DATE DATE REMITTED f AMOUNT <br /> FEE <br /> r <br /> LESS$ i <br /> PRORATION +. i <br /> PLUS-; <br /> PENALTY <br /> OTHER <br /> o b Ff� <br /> Received by Date Receipt No. Permit No. Nsuarice Date Mailed - Del <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES .1601 E.HAZELTON AVE.,P.O.Box 2009 STO TON,CA 5201 <br />