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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. , <br /> APPLICATION <br /> o. (For Non-Transferable, Revocable, and Suspendable) s �- <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joa uin Local Health Distrr' t <br /> Ar- <br /> y Business Name (DBA) . ,,AV7%*JWIV If �o� Address__.- 0 0•I' 40* lli''i'sfTp 44. <br /> a Owner— Address <br /> .I��M'T�jo�If __ Address <br /> Firm Partners, Addresses andTelephone Numbers <br /> E Business Telephone No. yz1Z i+ Emergency Telephone No. <br /> Contractor Licence No. S-8z <br /> LApplicants Name (Print) Aeeft _ Title Date <br /> 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) I <br /> Serial No. r CAL. License No. CAL. Liccnse Renewal No. - <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address " <br /> 2. ❑ PUMPER YARD r <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST y <br /> R.S. or R.C.E.Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> .� SANITATION PERMIT <br /> J <br /> ob Address! sk 3,Q/$ <br /> ocati n <br /> Owner_��IY J�i171g�?•s :. Address <br /> 211 SEPTIC TANK ❑ CESSPOOL JU LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT v <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR OTHER SGr�ps <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 r <br /> Type Construction Disposal Site 4 <br /> No. of Units Equipment Storage/Cleaning Location(s) wAl <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 l• <br /> Operator Name Where Certified <br /> Plant Location 1 <br /> I Plant Capacity <br /> I x 1 No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> s SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> L 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, a re latis of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> i <br /> I FOR DEPARTMENT USE ONLY .t <br /> F � <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1'&Received By July 31 <br /> i REMIT <br /> L' BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> } <br /> f+. `FEE <br /> k LESS w <br /> PRORATION R _ <br /> PLUS _ <br /> PENALTY 5 ' <br /> I OTHER <br /> OTHER . <br /> 7 <br /> `Received by I Dae - Receipt No.. Permit No ssua ce Date Mailed Delivered <br /> LICANT—RETURN ALL COPIES TO:Y ENVIRONMENTAL HEALTH PERM ITfSERVICES 1601 E.HAZELTON AVE.,P.O.Bo:2009 $TOCKTON,CA 4/2 1 <br />