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ApplicationsWil � Processed When Submitted Properly Completed. Be Sure To Sign The Appllcfftion. � „o <br /> FEB 14 1980 APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> SP-,N JOAQt;1N 1_ 4L `. ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Fi�! �- _- )�'made to carry on business in the jurisdictional area of the San Joaq in Local Health District <br /> rn Business Name (DBA) 4i � ,y`C�e-� T <br /> aOwner Addresst' <br /> Address <br /> a Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Q ` <br /> Contractor Licence No. `Z`3"'!6 Emergency Telephone No. 4 1?7 <br /> a <br /> L Applicants Name (Print) Title t ' <br /> Please check Applicable Category Date <br /> g ry (1-7)and Fill in a 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) <br /> Serial No, CAL. License No. <br /> Capacity �. CAL. Lfccnse Renewaf No. <br /> Gal„ Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER.,YARD J <br /> r-w <br /> For July 1, w'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 W <br /> R.S. Or R.C.E. No. <br /> Test Location f <br /> 4 <br /> 4. ❑ SANITATION PERMIT Test Date/Time � <br /> Job Address/Location V eF,ki 'S <br /> Owner Address Q <br /> SEPTIC TANK �OESSPOnl �[W LEACHING FIELD ❑ <br /> SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY 5rNEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site ` <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name <br /> Plant Location <br /> Where Certified <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 /> 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, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH <br /> ❑ January 1 &Received By January 31 ❑ July 1 8 Received By J73, <br /> E <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> EEE AMOUNT <br /> LESS I S <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received byDate Receipt No Permit o. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Issuance Date Mailed eliver d <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK ON,CA 52 <br /> - � <br />