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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ti <br /> ° APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> 4 I LIQUID WASTE <br /> I <br /> Application is�yher by made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> H Business Name (DBA) D/ �i�,JRRisw Se�S Address .6� `� � <br /> Z' Owner ��.Q. p� Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. � �G[� Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> Applicants Name {Print) 0,-47 c'� Title E� fin? Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> t 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> I Description(Make/Yr., Color) li <br /> FSerial No. _ CAL. License No. CAL. LicC se Renewal No. <br /> s CapacityWe <br /> M Gal., ights &`Measures-No.. <br /> Equipment Parking Address's <br /> 2. ❑ PUMPER YARD �N <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> I No. of Chemical Toilets Stored ` r ' - CL <br /> 3. ❑ PERCOLATION-TE <br /> ST it <br /> R.S. or R.C.E. Name R.S. or R.G.E. No. <br /> Test Location ) Test Date/Time <br /> 4. 9 SANITATION PERMIT I� <br /> Job Address/Location SSC - <br /> Owner 'ham �/�!�� � W5 i Address - • ' �� s <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE-PI-T--- -11-PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW J REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction IE Disposal Site <br /> I No. of Units II Equipment Storage/Cleaning Location(s) 1 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -.lune 30, 19 �. <br /> Operator Name E Where Certified <br /> Plant Location <br /> t Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -'June 30, 19 _ �-,:. ' <br /> SIZE: ❑ Less Than 1;000 Sq Ft., © More Than 1,000 Sq. Ft. .01 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - f <br /> -z <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of'the`Sa Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X c <br /> s. v-, <br /> nM FOR DEPARTMENT USE ONLY <br /> Fee Is Due.• ❑ ANNUALLYzIl. -E] PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received,By,Jan_uary-31._-❑.Jul' 1'&Received By Juiy 31 <br /> BILLING REMITTANCE $ - REMIT <br /> BASE <br /> EXPLANATION r.. AMOUNT DUE '� - CHECKED, <br /> DATE DATE REMITTED AMOUNT <br /> FEE " <br /> .n W <br /> LESSI <br /> —- ��-„---� <br /> PRORATION <br /> . PLUS !� <br /> PENALTY ! <br /> OTHER <br /> OTHER I; <br /> i t <br /> I� 1 —7 9,-7O FM`s <br /> Received by Date Receipt No. - Permit No. - Issuance Date Mailed livered - V77�1 <br /> APPLICANT RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON/AVE.,P.O.Box 2009 S OCKTO ,CA 95 <br />