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L Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. R <br /> APPLICATION <br /> (For Non-Transferable, Revocable, 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 /> Business Name (DBA) 2A /9i4e/S � Address 2749 1 If IA-16-k!Ir <br /> TXT• f <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers c�3� <br /> aBusiness Telephone No. T�� c/1v07 _ Emergency Telephone No. n <br /> Contractor Licence No. — 7 <br /> Applicants Name{Print) gf J9_�/�s fs�15 Title - ���7- Date �-��—8� <br /> Please check Applicable Category pp g ry (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL, License Renewal No. + <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 <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 Ion Test Date/Time <br /> 4. SANITATION PERMIT , ) <br /> Job Address/Location Z6. 85N• ! -714 oJeJJ"7 O� <br /> Ow�n'� �`C- f Address •0ak $ y �..¢ ����� <br /> � SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT 171 <br /> ©'PERMANENT ❑ TEMPORARY ANEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> Nb. of Units Equipment Storage/Cleaning Location(s) C <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 A` <br /> Operator Name Where Certified <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 /> I herebycertify that I have prepared this application and that the work will be done in accordance with San Joaquin Count <br /> Y P P PP 4 Y � <br /> ordinances, state laws, n Lules and regula ' sof a an Joaquin Local Health District. <br /> d <br /> APPLICANT'S SIGNATURE t <br /> B <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNITPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT � <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY t� i <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. I Issuabce Date Mailed eli red <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,.P.O.Box 1009 ST KTON, 95201 <br />