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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application: <br /> *7; , -APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) ...,..,r., <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is here y made tpo rry on busin s in the jurisdictional area of the San Joaquin Incal Health District <br /> y Business Name (DBA) f"(�Af-- <?3_1 Address �s l" }310 I�- ✓c "� + <br /> q Owner Ecd 1l.16&_,o E< `��TiS Address Z� ✓�t�f3-tet` i+�d <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. I�86 <br /> L Applicants Name (Print) J Title G 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) <br /> Serial No. CAL. License No. CAL. Liccnse Renewal No. �s <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address r <br /> 2. ❑ PUMPER YARD <br /> f <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> r <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST V� <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 5~Y /lC+lIv 1UG A <br /> .f=/�� I <br /> Owner U U _(�c�6f(' 1� _ Address 1/1G 34 S A e— all /L[V <br /> Q SEPTIC TANK ❑ CESSPOOL © LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ® PERMANENT ❑ TEMPORARY 9 NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL T I LjTS For July 1 J�ne 30, 19 ��f � � <br /> Type Construction I,f� Q Gl r //�f+/� Disposal Site Lys <br /> No. of Units Equipment Storage/Cleaning Location(s) 7 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location o <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. FL, ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> YyN <br /> 1 <br /> I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance wi San oaquin County <br /> ordinances, state laws, and <br /> ,r,Lu,lles and regulations of the San Joaquin L alth Distric ' <br /> APPLICANT'S SIGNATURE X AI & f� � <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT IXPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ �•` REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT" <br /> FEE <br /> LESS' <br /> PRORATION <br /> PLUS " <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No PL5rnit No. - Issuance Date Mailed D live d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITAERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC TON,CA 201 <br />