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- Applications Will Be Processed When Submitted Pioperly Completed.Be Sure To Sign The Application. �\ <br /> APPLICATION <br /> l t (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> r (y tl 1 ENVIRONMENTAL HEALTH PERMIT <br /> 4 LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA)_J> Address Ge.box 244 <br /> i Owner Address <br /> C <br /> J.Firm Partners,Addresses and Telephone Numbers <br /> I Business Telephone No. �-`G G- 9�a 7 • — Emergency Telephone No. <br /> Contractor Licence No. - <br /> S <br /> L Applicants Name (Print) <br /> F Lo YD (4;o o� Title Date <br /> I Please check Applicable Category(1-7)and FIII in the Required Information <br /> iF 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. License Renewal No. <br /> Capacity Gal.,Weights&Measures No. <br /> k Equipment Parking Address <br /> 2. ❑ PUMPER YARD ON <br /> For July 1, June 30, 19 <br /> No.of Vehicies Stored W <br /> No.of Chemical Toilets Stored W <br /> t 3, 0 PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S.or R.C.E.No. <br /> Test Location Test Date/Time— <br /> t 4. JX SANITATION PERMIT <br /> Job Address/Location dAe_4 <br /> Owner CA�Z 7�E d c af'•��.r�r 600A Address <br /> S`�©S /! PE2 Sfi�itJF3 7dC �d <br /> its) SEPTIC TANK 11 CESSPOOL <br /> A LEACHING FIELD X SEEPAGE PIT ❑ PACKAGE PLANT <br /> �IPERMANENT ❑ TEMPORARY NEW <br /> 13REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No.of Units Equipment Storage/Cleaning Location(s) <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name` Where Certified <br /> I Plant Location <br /> f No.Units Served <br /> Plant Capacity <br /> T. ❑ 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 /> 1 I hereby certify that I have prepared this application d that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules and regulations aft San quip Local Health District. <br /> I <br /> APPLICANT'S SIGNATURE X <br /> I <br /> t FOR DEPARTMENT USE ONLY <br /> it Fee Is Due: ❑ ANNUALLY PER UNIT JWPER SITE ❑ EACH ' ❑ January 1&Received By January 31 0 July 1 6 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE r A/ <br /> LESS -- <br /> f PRORATION <br /> PLUS <br /> r PENALTY <br /> OTHER <br /> F OTHER <br /> 79-810 ��r3/�y als's�. <br /> issuance Dale Malleo DOW ed <br /> Received by Date Receipt No. Permit No, <br /> 1 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE:,P.O.Box 2000 STO TON.C 95201 <br />