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Applications WIII Be Processed When Submitted Property Completed..Be Sure To Sign The Application. <br /> APPLICATION <br /> N_ (For Non-Translerable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> _I <br /> Business Name(DBA) QA AlovelS SL �o e/�;-�� Address <br /> aOwner Address i <br /> O.Firm Partners,Addresses and <br /> Telephone Numbers c� <br /> ECL <br /> Business Telephone No. T�I�— ��� Emergency Telephone No. n <br /> 1 <br /> Contractor Licence No. �� � e,5=, Date <br /> �Applicants Name(Print) t 5 Title <br /> Please check Applicable Category(1-7)and III In the Required Information r <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30.19 Disposal Sites ' <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. Liccnse Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 I <br /> No.of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E.Name R.S.or R.C.E.No. 1 <br /> Test L00 ton Test Date/Time <br /> 4. L� SANITATION PERMIT <br /> Job Address/Location L A aq f, T� T <br /> O,wn1 Address <br /> L'� SEPTIC TANK '❑ CESSPOOLErLEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT 1 <br /> C'3 PERMANENT ❑ TEMPORARY O—NEW ❑ REPAIR ❑ OTHER <br /> ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> pe Construction Disposal Site <br /> No.of Units Equipment Storage/Cleaning Location(s) A <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name <br /> Where Certified <br /> Plant Location <br /> d <br /> Plant Capacity No.Units Served 1 <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 /> Count <br /> 1 hereby certify that t h ve prepared this application and that the work will be done in accordance with San Joaquin y , <br /> ordinances, state laws, rules_" regula'os of a an Joaquin Local Health District. <br /> e <br /> APPLICANT'S SIGNATURE 1 <br /> R <br /> FOR DEPARTMENT USE ONLY y1y1y11 <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE EACH .❑ January 1&Received By January 31 Q July 1 Received 6y July 37 f <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEELESS <br /> PRORATION <br /> PLUS <br /> PENALTY tD � <br /> OTHER <br /> OTHER <br /> o s�3 <br /> Received by Date Receipt No. Permit No. Issu ce Date Mailed uielirred <br /> APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL WEALTH PERMITISERVICES loci E.HAZELTON AVE.,".Box 2009 .ST KTON 1119, <br /> 91 <br />