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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) i <br /> ENVIRONMENTAL HEALTH PERMIT t SEPTAGE <br /> LIQUID WASTE <br /> t Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> r Business Name (DB ) Address <br /> Address�� Z9 va`ri f rr� Az <br /> a Owner-o'-'2' <br /> 1A <br /> 0 Firm Partners.Addresses and TelephoneNumbers., aC1 <br /> aBusiness Telephone No. I Emergency Telephone No. <br /> Contractor Licence No. i <br /> LApplicants Name (Print) �'� Title Date <br /> I <br /> Please check Applicable Category (1-7) and ill in the Required Information 6` <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> I 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 /> E 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. ❑ SANITATION PERMIT a/ <br /> Job Addres Vcatibn 14r D 4r Q dCael A <br /> Owner Address 7,30 "G a o r� <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY + NEW ❑ REPAIR 13--OTHERS Ulm <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 /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity _,No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 301'19 <br /> I SIZE: ❑ Less Than 1,000 Sq. Ft., )'❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> cI <br /> I 1� <br /> C <br /> I hereby certify t ave p ared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, stat laws, and rules nd guI tions of<the <br /> eSSan Joaquin Local Health District. <br /> ! APPLICANT'S SIGNATURE)( c � - <br /> FOR DEPARTMENT USE ONLY <br /> 1 Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> r BILLING REMITTANCE $ REMIT <br /> I BASE EXPLANATION AMOUNT DUE CHECKED <br /> _ DATE '-� DATE REMITTED AMOUNT <br /> 1. <br /> FEE J01 <br /> ��� <br /> LESS Ilk <br /> PRORATION <br /> PLUS s <br /> PENALTY K- <br /> OTHER <br /> OTHER <br /> i <br /> -7lOLYOI 37 �� <br /> �.7 y <br /> Received by Dae Receipt No, Permit No. _ _ Issuance Date Mailed Delivere <br /> APPLICANT—RETURN ALL COPIES TO':-` ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.'HAZELTON AVE.,P.O.box 2009 STOCK ON,CA 95 1 <br />