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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application., <br /> APPLICATION <br /> r (For Non-Transferable, Revocable', and Suspendable) <br /> - ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> r <br /> Appiicat' is hereby to car usiness in the jurisdic nai area of th an JOa n Lo Health istr /� <br /> f Business Name (DBA `/gni Address � IC�f - <br /> i Owner ' Address <br /> Firm Partners, Addresses and Tel one Numbers <br /> 0. Business Telephone No. w.�3SaZ Emergency Telephone No. <br /> Contractor Licence No. { <br /> Applicants Name (Pri ;I r r Titie 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 I Disposal Sites <br /> k Description(Make/Yr., Color) <br /> Serial No. i 0 CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures.No. <br /> w•f <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD `` <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.G.E. No. <br /> Test Location !LiTest Date/Time <br /> 4. ❑ SANITATION PERMIT ��((9 'mss +- <br /> ¢ / i <br /> [ Job Addre s ovation;�Q 023 f�k� �� <br /> Owner /KEIT, '44 6-T-440y Address <br /> zw <br /> �- la SEPTIC TANK ❑ CESSPOOL= P=LEACHING FIELD ❑ SEEPAGE PI7_0_6\CKAGE:PLANT <br /> WPERMANENT ❑ TEMPORARY NEW ❑ REPAI`R ❑ OTHER <br /> f ,i✓ <br /> 5. ❑ CHEMICAL TOILETS For July 1 -June 30, 19 <br /> Type Construction '! I f Disposal Site <br /> No. of Units "") Equi ment Storage/Cleaning Location(s) <br /> I. 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ' <br /> : i. Where Certified <br /> Operator Name _ I } <br /> Plant Location - <br /> Plant Y Ca acit No. Units Served <br /> P <br /> 7. ❑ LAUNDRY For July 1, -June 30, 49' <br /> SIZE ❑ Less Than.1,000 Sq. Ft., El More Than 1,000 Sq. Ft. <br /> 11 DRY-CLEANING, Chemicals Used/Amount/Mo. <br /> ,Homeowrtarorlicensedagant'ssignature certifiesthe otf perj/f_fr <br /> in su a �y(, e s s' la <br /> �_., <br /> CC o ub z g O. 0.tura certifies the ot3owigg: "I certify that iia th erfo ante t e r which t i i ,II shat <br /> persons subject to workman t,o lue:nsation laws of Californi ." <br /> I <br /> hereby certify that l have pre d this application an that the I rk will be done in accordance with San Joaquin County <br /> [` ordinances, state laws, and and r gulations o aquin Local Health District. <br /> f ; <br /> APPLICANT'S NATURE � } <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due ANNUALLY ANNUALLY ❑ PER UNIT .. _ ❑ PER SITE 11EACH __January 1-&.Received,By_January-3.1—0-Julys f&Received By July 31 <br /> a. REMIT <br /> BILLING REMITTANCE.,. /$R. AMOUNT DUE CHECKED <br /> - BASE - EXPLANATION - -- <br /> DATE DATE ,_ REMITTED, -:�s� y AMOUNT <br /> t 1f <br /> I FEE <br /> LESS r <br /> PRORATION <br /> PLUS <br /> i <br /> PENALTY t - <br /> # OTHER /A fu <br /> OTHER <br /> Received•by Date Receipt No. Permit No. 1 suane Date i d Delivered .Aft- <br /> C. <br /> APPOCANT—RETURN ALL COPIES TO:x ENVIRONMENTAL HEALTH PERM ITISERVICES 1601 E.HAZELTON AVE:, 009-. STOCRTON,'CA 95201 <br /> a�� r. F <br />