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J Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Appii+gption. <br /> APPLICATION --1 <br /> ( , (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGF <br /> LIQUID WASTE <br /> Applica ' "rebW-rLiadetocar on bu�ness in the juri�sdicYionaI area of the San Joaquin Local Health District S <br /> rBusiness Name (D A) <br /> `- _Address L� cS� � �T <br /> a Owner_ s c-V��CC _ Address IAS ,L <br /> J Firm Partners, Addresses and I phone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. 316 J <br /> L Applicants Name (Print) '� Title z Date <br /> PleaseEcheck'Applicable.Category(1-7)and Fill In the Required Information r <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> I .��.,t l <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr„ Color) . <br /> Serial No. CAL. License No. a 1 CAL. License Renewal No. Q <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> f For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> E 3. ❑ PERCOLATION TEST r <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- Y1 <br /> Job Addre ocation U�� ��C 5� �'04 �" �a�. ' &dORZI" � <br /> Owner S Address Q ` /s- S 75 SP 7p ,gyp <br /> t SEPTIC TANK ❑ CESSPOOL XLEACHINGFIELD WrSEEPAGEPIT ❑ PACKAGE PLANT i <br /> 1W PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. D CHEMICAL TOILETS For'July 1;;oJuunne.30, 19 <br /> Type ConstructionA <br /> Disposal Site <br /> No. of Units ',.Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT' Fdr,July 1, -June 30, 19 <br /> Operator Name _ Where Certified <br /> Plant Location- , <br /> Plant Capacity % L ) No. Units Served <br /> 7. ❑ LAUNDRY For July 1 -June3D, 19 <br /> SIZE: ❑ Less Than 1,000 6q. Ft., ❑ MoreThan 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/M9.. <br /> hereby certify thrt I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,,a ules_and regula ions of the an Joaquin Local Health District. <br /> 4� . .__. ` <br /> APPbbAN S SIGNATUR <br /> t r a41. <br /> ---. FOR- —P RTMENT USE ONLY <br /> ts iEr <br /> Fee Is Due: ❑ ANNUALLY5 I"Ll PER UNITQ ❑Ep R'S 7E ;;❑ EACH r❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE - EXPLANATION BILLING 'REMITTANCE .-.g= $ REMIT <br /> DATE DATE IhREMITTED AMOUNT DUE CHECKED <br /> FEE L V y jj AMOUNT <br /> -h"i 4 <br /> LESS ... <br /> PRORATION <br /> PLUS <br /> -PENALTY <br /> OTHER <br /> OTHER # <br /> LO a <br /> �� b `. <br /> Received by Date Receipt No PermitNo. issuance Date Merited Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL MEALTH,PERMIT/SERVICES _ �1� LTON AV�,P.O.Box 20ST8CK70N,CA 95201 <br />