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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> = ENVIRONMENTAL HEALTH PERMIT SEPTA G E YY t <br /> LIQUID WASTEt <br /> a Appli�ation ere6tr Lade to c' on business it he jurisdictional area of the San Joaquin Local Health District <br /> Business BA r� r` ! <br /> a Owner /x`1'1 � ��// Address <br /> Firm Partners,Addresses and TAddress <br /> elephone Numbers <br /> aBusiness Telephone No. C's iffy <br /> Contractor Licence No. Emergency Telephone No. \ <br /> Q <br /> L Applicants Name (Print) T#%7 RG1/e <br /> Please check A Iicable Category ) Title �"'Lr Date <br /> PP g ry(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) v <br /> Serial No. <br /> k Capacity .CAI_. License No. <br /> CAL. Lic.:�se Renewal No. <br /> Gal., Weights 8, Measures No. <br /> Equipment Parking Address <br /> f 2. ❑ PUMPER YARD A <br /> ' For July 1, June 30, 19 <br /> No. of Vehicles Stored (� <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name <br /> Test Location <br /> R.S. or R.C.E. No. <br /> 4. 0 SANITATION PERMIT ty Test Date/Time <br /> Job Address/Location <br /> Owner m9gy y t'NeMj AA/ Address 7 <br /> IE SEPTIC TANK El CESSPOOL ® <br /> IE LEACHING FIELD ❑ SEEPAGE PIT 11 PACKAGE PLANT <br /> PERMANENT ❑ <br /> TEMPORARY ® NEW 0 REPAIR ❑ OTHER f <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30,19 <br /> Type Construction Disposal Site <br /> No. of Units - Equipment Storage/Cleaning Location(s) <br /> fi. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name <br /> Plant Location Where Certified <br /> Plant Capacity <br /> 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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - <br /> I hereby certify that I have prepared this application nd that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and <br /> frreguI ns of I San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> .f <br /> l <br /> FOR DEPARTMENT USE ONLY i <br /> Fee Is Due., ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE <br /> 11 EACH nuary 1 &.Received By January 31 <br /> ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BELLING R MI OE ," <br /> $ REMIT <br /> D TE E REMITTED - AMOUNT DUE CHECKED <br /> FEE AMOUNT r <br /> LESS T — ' <br /> PRORATION <br /> PLUS <br /> PENALTY <br />.� OTHER <br /> OTHLR <br /> .� a7 7 "fig- <br /> Received by ate <br /> ,Receipt No. Permit No, I , <br /> APPLICANT-RURN ETALL'CDPYES TO: ENVIRONMENTAL HEALTH PERuanc Date MIT/SERVICES _ Mailed ed 5 <br /> 50.t E.-FtA2ELTON AVE.,P.O.Box 2009 S s ` <br /> �' � 70CKTON,CA 95�- <br />