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c Applications Will. 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 /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health Distrl�jt �j <br /> NBusiness Name (DBA) Address –� l S7 .4,1 g <br /> z Owner Address , <br /> 4 <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. _ ?4pD7 Emergency Telephone No. <br /> -J Contractor Licence No. vp <br /> Applicants Name (Print) <br /> Title �IafAri��– Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information F <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. L{cense RenewalNo.— <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address j <br /> 2. ❑ PUMPER YARD <br /> { <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 /> A. I SANITATION PERMIT <br /> Jab Address�/Loocaattion 71� �'iIr/�t/ <br /> Owner .,A�- Z720, Address /V/3 +` dGCJ-11L1' <br /> ETSEPTIC TANK ❑ CESSPOOL CILEACHING FIELD WSEEPAGE PIT ❑ PACKAGE PLANT <br /> B^PERMANENT ❑ TEMPORARY KNEW ❑ REPAIR ❑ OTHER <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 /> ti. ❑ 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 s <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> .4. ♦ -r ice....- �� `Y•� ...4 - <br /> I hereby certify that I h e prepared this application and that the:'work will be done in accordance �i an Joaquin County <br /> ordinances, state laws d regula ' s of a S#n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> c-FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY PER UNIT PER SITES ❑-EACH' F0_1January 1 &Re By January 31 ❑ July 1 &Received By July <br /> REMIT <br /> ' BASE EXPLANATION a ' BILLING REMITTANCE S AMOUNT-DUE CHECKED <br /> DATE DATE MITTED AMOUNT <br /> r #y <br /> FEE L: (4, <br /> LESS <br /> PRORATION' <br /> PLUS <br /> PENALTY <br /> ! OTHER R <br /> e a � <br /> OTHER <br /> Received by Date Receipt No, Permit No. I Issuandb Date�. Mailed Deliver d <br /> i - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES '1601 E.HAZELTON AVE.,P.O.Box 2009 STOC ON,C .95201 <br />