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Applicatio s Will Be Processed When Submitted Property Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferabie, Revocable, and Suspendable) " <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicati is hereby made to,�carry on business in the jurisdictional area of the San Joa uin Local Health District <br /> m Business N e (DBA) � �de.e ✓.4.�//� ��� Address <br /> aOwner ` :.1 y Address 266 <br /> J Firm Partners, Addresses and Telephone Numbers SAF iii <br /> aBusiness Telephone No. -�r1. � Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name(Print) f - Title 0 114,%— Date l0 -a& <br /> Please check Applicable Category (1-1) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) J <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. l <br /> Capacity_ Gal., Weights & Measures No. I <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 <br /> R.S. or R.G.E. No. (� 4 <br /> Test Locationw Test Date/Time a <br /> 4. 25SANITATION PERMIT.. <br /> Job Addres Location <br /> Owner Address <br /> 0 SEPTIC TANK ❑ CESSPOOL 0-LEACHING FIELD 2SEEPAGE PIT- <❑ PACKAGE PLANT I, <br /> WPERMANENT ❑ TEMPORARY ® NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 f <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 T r, <br /> Operator Name Where Certified 1 <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 /> —T <br /> I hereby certify that I have prepared this applica ' n and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rulesreglations f e an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X. <br /> ) <br /> FOR DEPARTMENT USE ONLY <br /> Fee.IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT a <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> �,ry/` AMOUNT t <br /> FEE •SI �� l� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER i <br /> OTHER <br /> Received by Date Receipt No Permit No. Issuance ate Mailed �. eliv ed :� <br /> APPLICANT RETURN ALL COP ESTO: ENVIRONMENTAL HEALTH PER T/SERVICES - 1801 E.HAZELTON AVE-P 0-11 2009' -STO JTON,CA 95201 :1 <br /> y iA(20-14 -7:14 �/rt� r //- 5= ?� -I_.W,�"--M_- �/., ? 4o. h <br />