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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ` <br /> f � I APPLICATION w , <br /> (For Non-Traie9ierablp,�Revocable,and Suspendable) <br /> ` ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE i <br /> f Application is hereby made to carry on business in the jurisdictional area of theono quin L al Health District <br />' .n Business Name (DBA)I F-y � f\1� L L BfL C Lh N5 Address C <br /> z Owner �� r �qkf Address 3S L� U i:k K31; . <br /> 4 <br /> Firm Partners, Addresses a Telephone Numbers <br /> a Business Telephone No. Emergency Telephone No. <br /> Q <br /> Contractor Licence No. S j _ t <br /> Applicants Name (Print) L ��t 1 `T N L.1 Title Date <br /> Please check Applicable Category (1-7) and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) iI <br /> For July 1, June 30, 19 f Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. r_'CAV License Renewal No. <br /> Capacity r"� al Weights&7_Mea9ures Nom <br /> Equipment Parking Address } <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 i <br /> No. of Vehicles Store d_. T i <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 <br /> Job Address/Location �� 3� — S <br /> r � <br /> i Owner r TF—M al Address <br /> ❑ SEPTIC TANK^ -❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT -❑ PACKAGE.PLANT G"� <br /> ❑ PERM ANENT . ❑ TEMPORARY i❑ NEW REPAIR 13 OTHER r <br /> 5. 11 CHEMICAL TOILETS For,July 1, -June 30, 19 ! <br /> Type Construction ' Disposal Site <br /> No. of Unitsr )r # Equipment Storage/Cleaning Location(s) <br /> y 6. ❑ PACKAGE TREATMENT PLANT For July 1, -,June 30, 19 T <br /> a <br /> Operator Name r Where Certified <br /> Plant Location. <br /> r <br /> Plant Capacity 1 I No. Units Served <br /> 7. ❑ LXUNDRY- Forly , -June 30, 19 <br /> SIZE:' U Less Th 1,000 Sq-ft.,4 More Than 1,000 Sq_Ft. t" <br /> ` ❑ DRY CLEANING, Chemicals Used/Amount/Mo <br /> I hereby ce ! have prepared this application and that the work will be done in accordance with San Joaquin County <br /> {. ordinances, state laws d rules and egula ion o the Sa Joaquin Local Health District. a <br /> 1 r } s <br /> r <br /> APPLICANT'S SIGNATURE <br /> t q4 FOR DEPARTMENT USE ONLY 4 <br /> Fee IS Due: ❑ ANNUALLY t] PER UNIT PER SITE ❑ EACH ❑ January 1 d Received By January 31 3 El July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ i" •! <br /> BASE EXPLANATION AMOUNT DUE CHECKED^ �, <br /> " DATE DATE REMITTED AMOUNT - <br /> FEE �JI ice' <br /> LESS <br /> PRORATIONPLUS <br /> r <br /> PENALTY : N 1 1 U f F <br /> U - 4 <br /> OTHER- <br /> OTHER - <br /> - <br /> I . <br /> Recdived by at Receipt Np!; Permit No. Issuance tiale Mailed Deliver <br /> APPLIGA,NTrRETUANRLL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601'E.HAZELTON AVE.,P.O.Box 20.09.,-,.STOCIy ON,CA. 5201..- <br />