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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) / SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is herema e to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> m Business Name (DBA) A -, 60 Al S 77?�&CL7-e 0 Address_/!'Z 4• #M eZ-6 SAle-l✓ <br /> z Owner Address <br /> a - <br /> J Firm Partners, Addresses and Tel phone Numbers_ <br /> CL <br /> Business Telephone No. �� '� /� -_ -_-- Emergency Telephone No. . <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title e 9&, Z6:E Date - <br /> Please check Applicable Category (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) d <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 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 R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. X SANITATION PERMIT <br /> Jab Address/Location E - IF L -� °J <br /> Owner _7729 M .. /< Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> Jl� PERMANENT ❑ TEMPORARY ❑ NEW REPAIR OTHER 5V0114 1 <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 Where Certified <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 /> 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 regul ions of t an aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 1� FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY © PER UNIT la:PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMDUNT pUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> EEE <br /> LESS <br /> PRORATION , f <br /> PLUS <br /> PENALTY <br /> OTHER t <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivere <br /> APPLICANT—RETURN ALL COPIES TO: ENWRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK ON,CA 900/1= <br />