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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> - 4 APPLICATION <br /> i ~ (For Non-Transferable, Revocable,and Suspendable) II <br /> ENVIRONMENTAL HEALTH PERMIT ' SEPTAGE <br /> t LIQUID WASTE <br /> r Applica ' is hereb made to carry on business in the jurisdictional area of the San Joaquin Local Health District Q <br /> Business Name (D A) Q } <br /> aOwner c �,G/4/ Address7- d <br /> Firm Partners, Addresses and Telephone Numbers Address <br /> s <br /> 0. Business Telephone No. <br /> Contractor Licence No. to Emergency Telephone No, <br /> L Applicants Name (Print) r <br /> Please check Applicable Category(1-7)and Fill in the Required Information Title Date 4 <br /> d <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 <br /> Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. <br /> Capacity Gal., Weights 8 Measures No. CAL. License Renewal No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored al <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name <br /> Testi Location R.S. or R.C.E. No. <br /> 4. Rr SANITATION PERMITTest Date/Time <br /> l �f <br /> Job A ess/Location F,Si�!3 <br /> Owner � E �Q I< , CIO, s <br /> J ` <br /> Address (, /j J'Gc � ��r- <br /> SEPTIC TANK ❑ CESSPOOL ALEACHING FIELD <br /> PERMANENT ❑ TEMPORARY SEEPAGE PIT ❑ PACKAGE PLAINT <br /> $• ❑ CHEMICAL TOILETS For July 1, -u e 30 19 SEEPAGE <br /> 11 OTHER <br /> Type Construction <br /> Disposal Site A <br /> No. of Units ,n <br /> Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July,1, -June 30, 19 <br /> Operator Name <br /> Plant Location Where Certified <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 No. Units Served <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br />❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> ordinances, state laws, r and regulations of the Sa Joaquin Local Health District. with San Joaquin County i <br /> APPLICANT'S SIGNATURE X 11 r <br /> FOR DEPARTMENTUSE ONLY 1 <br /> Fee Is Due: ❑ ANNUALLYa <br /> -❑ PER UNIT PER SITE El EACH <br /> January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION _BILLING REMITTANCE $ - . . REMIT <br /> DATE DATE REMITTED AMOUNTD UE CHECKED <br /> FEE /� AMOUNT <br /> LESS <br /> PRORATION t { <br /> PLUS <br /> PENALTY +{ <br /> OTHER <br /> OTHER � <br /> - g �� . 96 <br /> P + <br /> Received by date - -Receipt No. i <br /> ermit Np- I an Date Mailed D <br /> �y APPLICANT-RETURN ALL COPIES TO! = ENVIRONMENTAL HEALTH pEgMlT/SERYICES-i'��• eliver tl <br /> -- - „x,1601 E.HAZELTON AVE.,P.Woox2009 -STDG TON,C 5201 - <br />