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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) <br /> r ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatio ' hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health istri <br /> F Business Name (DBA) k (�lJ►r' 9 S Address z.* ALe=b <br /> aOwner :51 Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> � <br /> a Business Telephone No,xj/,17 41:9 ID / _ Emergency Telephone No. <br /> Contractor Licence No. �( <br /> ,moi <br /> L Applicants Name(Print) �` Title 0—WA 1- Date <br /> Please check Applicable Category (1-7)and Fill in the Required Iniormation <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. 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 7N <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/--jjocation l / A! aA <br /> Owner V4y--- 139>!fM'< Address <br /> 9 SEPTIC TANK ❑ CESSPOOL ® LEACHING FIELD 0 SEEPAGE PIT ❑ PACKAGE PLANT <br /> IN PERMANENT ❑ TEMPORARY IN NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ 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, n -rule and regulaion of the San Joaquin Local Health District. <br /> 1.APPLICANT'S SIGNATURE X . r <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & ceived By January 31 ❑ July 1 &Received By July,31 <br /> REMIT <br /> BILLING DEMI ANCE $ <br /> BASE EXPLANATION PATE IT ED <br /> AMOUNT <br /> CHECKED <br /> AMOUNT <br /> FEE <br /> LESS �! <br /> PRORATION v STL�� <br /> PLUS r <br /> PENALTY <br /> OTHER <br /> OTHER <br /> q - 6 7 k VIM f <br /> Receiv b Date Receipt o. Permit No. Issu ce to Mailed Delivered <br /> AP,R. IGANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PER 1601 E.HAZELTON AVE.,P.O.box 2009 STOCKT N,CA 95 01 �+ <br />