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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 he by made to Carr yon b usii <br /> ness in the jurisdictional area of than J quin Local Health District t <br /> rn Business Name (DBA)p-� ,� 5 �(7 C . _ Address-1 P. . � I soq�"�` /V <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. — D7 Emergency Telephone No. <br /> a <br /> Contractor Licence No. Z <br /> L Applicants Name (Print) :11. <br /> 1 Title �`r Date �) <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> a 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) � <br /> For July 1, - June 30, 19 :i� Disposal Sites <br /> 1 <br /> Description(Make/Yr., Color) _i � <br /> Serial No. ir CAL. License No. CAL. License Renewal No. <br /> Capacityg�� Gal., Weights & Measures No. W <br /> ` Equipment Parking Address )� <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored i <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�Lo�tion 11 Test Date/Time <br /> 4. L'J SANITATION PERMIT h <br /> n <br /> Job Address/Locat1 n .S>'12gG , Lam$ t3 S A <br /> Owner g CJ::Q2-- Address 0- 15-7 Al u <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT .n. <br /> Q PERMANENT ❑ TEMPOR'ARY ❑ NEW C�EPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS Forte my 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> 1 <br /> No. of Units Equipment Storage/Cleaning Location(s) {� <br /> 6. ❑ PACKAGE TREATMENT PI.A NT For July 1, -June 30, 19 <br /> Operator Name ,I�, Where Certified <br /> Plant Location t <br /> Plant Capacity No. Units Served y�j <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19. , <br /> SIZE: ❑ Less Than 1,000 Sq, Ft_, El More Than 1,000 Sq. Ft. a ? <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> I <br /> I hereby certify that I ha prepared this application and t at the work will be done in accordance with San Joaquin.County <br /> ,ordinances, state laws, egulatio f the Joaquin Local Health Districts <br /> APPLICANT'S SIGNATURE X II <br /> Z.0 II <br /> FOR DEPARTMENT USE ONLY <br /> Fed IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 R Received By Januar 31 Y ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION $ <br /> DATE DAT -TED AMOUNT DUE CHECKED <br /> i <br /> E REMI <br /> AMOUNT <br /> FEE III, <br /> LESS �L i <br /> PRORATION' P I <br /> PLUS �MI <br /> PENALTY yyyllI <br /> OTHER 6 ` <br /> Is t 1 <br /> OTHER <br /> - hili <br /> Received by Date Receipt No. Permit No. �+ <br /> u is <br /> Date Mailed De r <br /> APPLICANT—RETURN ALL <br /> COP <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES. 16-ill E.HAZELTON AVE.,P.O.Box 2009 STOCK 4N,CA 95 01 <br />