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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transfera er able,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE ; <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name (DBA) R JK S&A/S Address P A/ Z�O <br /> aOwner Address <br /> Z Firm Partners, Addresses and Telephone Numbers `F <br /> CL <br /> Business Telephone No. G/, -04-07 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) OO l Title - 407— /1Me— Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) f <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color)_ <br /> Serial No. CAL. License No. CAL. Lica ,e Renewal No. t <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD 0 <br /> For July 1, June 30, 19 r <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.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT ' <br /> Job Address/Location .3 49 N W/ -S-1? 4 C, <br /> 2 <br /> owner AIOA st!" �.��P .27'/�S - Address s P <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD K SEEPAGE PIT El 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 /> t <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> i <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 e <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 4 <br /> I hereby certify that I hav pared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state lawsegulations of the S in Local Health District. <br /> APPLICANT'S SIGNATURE X , Joaqu <br /> rule and r <br /> FOR DEPARTMENT USE ONLY <br /> . h <br /> Fee IS Due: ❑_ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION <br /> BILLING REMITTANCE $ 3 <br /> AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> _ AMOUNT <br /> FEE 7 S 4 <br /> LESS <br /> PRORATION <br /> PLUS 1q <br /> PENALTY <br /> OTHERAllft� 9L <br /> 1 <br /> OTHER <br /> Received by Date Receipt No.. Permit No, Issuance Date Mailed DyveAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boy2009 ST , A 95 d. _ <br />