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Applications Will Be Processed When Submined Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> k (Far Non-Transferable, Revocable, and 5uspendable) Ill <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE p <br /> LIQUID WASTE <br /> F Applicati i5 hereby ma to car on business in�he uri3diCti nal area of the San Joaquin cal Health District <br /> w Business Name(08A) +� f� Address � �� �"�� r <br /> owner L _ Address_ 17-OS- <br /> Fir <br /> m <br /> 7-O5Firm Partners,Addresses and T le hone Numbers <br /> Business Telephone Na. —' Emergency Telephone No. <br /> �Contractor Licence No._ ``ff <br /> L Applicants Name (Print) pp <br /> Title Date�7 -9 <br /> Please check Applicable Category(1-7)and Fill in the Required Information �+ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> f For July 1, June 30, 19 '' Disposal Sites <br /> Description(Make/Yr„Color) <br /> Serial No. _ CAL. License No. CAL.License Renewal No. <br /> Capacity Gal.,Weights&Measures No. <br /> Equipment Parking Address <br /> k• 2. ❑ PUMPER YARD j x <br /> For July 1,- - June 30, 19 7( <br /> No.of Vehicles Stored Q <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, I <br /> Test Location Test Date1T•sme Q <br /> 4. )9 SANITATION PERMIT - f <br /> Job AddresslLocalion f <br /> Owner ,. Address I D Ifdl <br /> �. SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT _ <br /> IW PERMANENT ❑ TEMPORARY PrNEW ❑ REPAIR ❑ OTHER 3 <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No.of Units Equipment Storage/Cleaning Location($) f <br /> 5. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Oparafor Name _ Where Certified <br /> Plant Location I <br /> Plant Capacity I No.Units Served <br /> 7. 1:1LAUNDRY For July 1, -June 30,119 <br /> I. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.. ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/AmAunt/Mo. _ <br /> r 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 ules and reg $tions of the San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X + _ <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Rue. © ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 -❑ July 1 Received By Juiy 31 <br /> - _ <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S <br /> GATE DATE REMITTED AMOUNT DUE CHECK <br /> L AMOUNT ,l <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY " <br /> OTHER <br /> .r <br /> OTHER �A. aJ <br /> f <br /> Received by Date Remipl No. Permil No. Issuance Date Mailed Delivared + A <br /> • •APPLICANT—RETURN ALL-COMES TO: ENVIRONMENTAL HEALTH PERMIT/BERYICES 1601 E.HAZELTO N AVE.,P.p.Bok $To K CA 201 <br /> E. � M97� <br />