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itted Property <br /> Applications Will Be Processed When SubAmPP`ICATION <br /> {For NonITRrONMENTAL HEALTH PERMIT le) SEPTAGE <br /> =� ENV 0 65— 30,--0.3 <br /> LIQUID WAST <br /> Application hereby m de to carryon business in the jurisdictionalparree of <br /> sthe San Joaquin Local Health D <br /> y Business Name (DBS ` Address ` <br /> 4 Owner <br /> 1 <br /> Firm Partners, Addresses and Telepho Numbers Emergency Telephone No. <br /> CL Business Telephone No. f pate 2 c <br /> Contractor Licence No. Title <br /> II pplicants Name(Print) <br /> L <br /> tegory (1-7)and Fill if Required Intormatio.n <br /> Please check Applicable Ca —� J <br /> j, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH tes VEHICLE) <br /> i DisposalFor July 1, June 30, 19 <br /> CAL. License Renewal No.' <br /> i;Ipescription(Make/Yr.,Color) CAL. License No. l <br /> €'serial No. <br /> Gal.,Weights &Measures No. t <br /> Capacity <br /> Equipment Parking Address <br /> Z, ❑ PUMPER YARD , <br /> For July 1,� June 30, 19 i <br /> 'No. of Vehicles Stored <br /> No. of Chemical Toilets Stored '=! <br /> ig- ❑ PERCOLATION TEST R.S.or R.C.E.No. <br /> i R.S.or R.C.E. Name F Test Date/dime � <br /> t Test Loc tion v <br /> r it/L s ��?j <br /> q �NITATION PERMIT !/ <br /> Job Address/Loc on Address, ,� <br /> Owner �ACI{ING FIELD iSEEPAGE PIT ❑ PACKAGE PLANT <br /> ( ❑ CESSPOOL ❑ REPAIR ❑ OTHER <br /> SEPTIC TANK 11 NEW <br /> 0 PERMANENT ❑ TEMPORARY <br /> 5, ❑ CHEMICAL TOILETS For July 1,-June 30, 1Dlspo Iso Site <br /> Type Constructioncation{s) <br /> r 'l <br /> Equipment Storage/Cleaning Lo <br /> No.of Units <br /> —6 ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> ` Operator Name- <br /> � lant Location No, Units Served <br /> Plant Capacity <br /> June 30, 19 <br /> 7- ❑ LAUNDRY Far July 1.- , ❑ More Than 1,000 Sq, Ft. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., <br /> a ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> Tcertif that I haveprepa d this application and t Joaquin Local�H Health District. <br /> ll be done in ccord"ante with San Joaquin County <br /> I hereby Y re lations the S <br /> ordinances, state laws, and rul <br /> I APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY. <br /> ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdE6^ITuly 31 <br /> I t Fee IS Due: C3 ANNUALLY ❑ PER UNIT ❑ PER SITE - $ -AMOUNT DUE CHECKED <br /> BILLING REMITTANCE - REMITTED - AMOUNT <br /> BASE EXPLANATION DATE DATE <br /> � n <br /> FEE \ <br /> LESS <br /> PRORATION <br /> PLUS r <br /> PENALTY <br /> OTHER ^� <br /> OTHER ..1. CX'�0rt`� •. <br /> Mailed Issuan a atd Delivered <br /> e CA 95201 <br /> Permit No. . <br /> e Receipt No. 1601 E.HAZELTON <br /> Received by pat <br /> AVE..P.O.Bax 2009 STOGKTO , <br /> S TO: ENVIRONMENTAL HEALTH PERMIT/SERVICE <br /> APPLICANT—RETuAN ALL CO NE <br />