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a. 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 SEPTAGE <br /> LIQUID WASTE <br /> Applica#i reb /�a e t rry n businessmen LIQUID <br /> of the Sa Joaquin al FiegIth District <br /> �;Business Na (DBA) nsil /r �h0�' .'Yc�� +�. <br /> aOwner rrI C�gRG1J� Address /�� b,l 1 <br /> Firm PAddress <br /> artners, Addresses and�eelleSpphone Numbers <br /> aBusiness Telephone No. J- ICS <br /> Contractor Licence No. 'V J$ Emergency Telephone No, <br /> L Applicants Name (Print) I <br /> Please check Applicable Category Title Date <br /> 9 ry (1-7)and Fili in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 <br /> Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. <br /> Capacity Gal., Weights & Measures No. CAL. Li -;e Renewal 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 <br /> Test Location R.S. or R.C.E. No. <br /> 4. ❑ SANITATION PERMIT Test Date/Time <br /> Jab Address Location 141 Z -7 <br /> Owner / AV R Ad .�1 <br /> SEPTIC TANK CESSPOOL CSI LEACHING FIELD Address <br /> N. <br /> ❑ PERMANENT © TEMPORARY ($ NEW SEEPAGE PIT 11 PACKAGE PLANT <br /> 5. E] REPAIR ❑ OTHER <br /> ❑ CHEMICAL TOILETS For July 1, -June 30, 19 _J <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 <br /> Plant Location Where Certified <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 No. Units Served r <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 a work will be done in accordance with San Joaquin County ` <br /> ordinances, state laws, and regulations a San J, uin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE <br /> ❑ EACH El January 1 8 Received By January 31 <br /> 13 July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by 7/Z <br /> Date� O t Recei No. <br /> P Permit No. Issuance Date Mailed 2>^ 1 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Deliver d <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC ON,C <br />