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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION ' <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAOE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> t � <br /> LIQUID WASTE , '. <br /> --a---Application is hereby made to carry on�bu�siness in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name (DBA) !)-Ar . AID�Is,4J t0 Address �• �� �f '�) t � r <br /> i Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 4(2(,[— Emergency Telephone No. <br /> Contractor Licence No. <br /> I <br /> L Applicants Name (Print) � � � Title -F bAA7V 9Dale <br /> Please check Applicable Category (1-7) nd Fill in the Required Information <br /> 1. 11 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 /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July i, 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 R.S. or R.C.E. No. <br /> TestLoc Test Date/Time <br /> 4. © SANITATION PERMIT <br /> Job Address/Location 2570 ' ' s(a-PA S-r-, C <br /> Owner 1 r'] Y� `rc=�- Sfr r�f5 Address 7A <br /> u JEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> `❑PERMANENT ❑ TEMPORARY ❑ NEW ❑ 141PFAIR ❑ OTHER <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 /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name a Where Certified t <br /> Plant Location <br /> 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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. _ <br /> .. - -W+ <br /> I 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, Ad rules an bgulatto of the p Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X r <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jufy 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> SASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE 'REMITTED <br /> AMOUNT <br /> f <br /> FEE �nO <br /> LESS ° <br /> PRORATION <br /> PLUS f <br /> PENALTY <br /> OTHER <br /> OTHER <br /> eceiv d Date Receipt No. Permit No. Issua ce a e Mail De ivere <br /> APP ANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P. . 009 A 95201 <br />