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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby ma de to cara on business in the jurisdictional area of the San Joaquin Local Health istrict <br /> hBusiness Name (DBA) /e, _✓ -.�-��� Address 7 <br /> aOwner Address �°-4' <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone No. 3d,9"IGlnS <br /> P Emergency Telephone No. 4'1 <br /> Contractor Licence No. z�ZZ _ <br /> Applicants Name (Print) Pes T- n 8613 kz a C Title rW5 Date 46—4 74/ OCali <br /> Please check Applicable Category (1-7) and Fill in the Required Information .9 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites ' <br /> Description(Make/Yr., Color) <br /> y <br /> Serial'No. CAL. License No. CAL. Liccnse Renewal No. Z;f <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No, of Vehicles Stored t <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. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT n <br /> Job Address/Location <br /> Ovyfier Address C� Z 2. C.�cs J—_2 3 <br /> [9 SEPTI TANK ❑ CESSPOOL104 ,LEACHING FIELD I-SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, June 30, 19 <br /> Operator Name Where Certified I <br /> Plant Location # <br /> Plant Capacity No. Units Served - <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> - w <br /> . r <br /> 1 <br /> 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, and r es and regulations of the San Joaquin Local Health District. <br /> h <br /> APPLICANT'S SIGNATURE X <br /> • <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 ' <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUN <br /> FEE <br /> v - l <br /> LESS J <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Iss anc Date Mailed Dell ed 11 <br /> q <br /> APPLICANT=RETURN ALL'COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 HAZEy]ON AVE ,.p�x 2009 $Tp KTON, A.95201 / <br />