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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 Q� <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District a <br /> Business Name (DBA)_iZ 19eyM a'!!r4 -y- -5o eV _Address DC7,/3p //b /4?odesTp C!j 9�3s3 <br /> Z Owner_ 1^ae <br /> K Address Steve.y p <br /> � <br /> Firm Partners, Addresses and Teleph' <br /> one Numbers - <br /> aBusiness Telephone No. S 3— Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) G wr aTitle Date 17— 9 — �3 <br /> Please check Applicable Category (1-7) and Fill in the equired Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 0 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) JD <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 /> n <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 Location Test Date/Time <br /> 4. If SANITATION PERMIT � � <br /> Job Address/Location 0'J 3 SC'- yi¢if/ �yL 1 C-ov f E.SGALati`� , <br /> !-Ve <br /> Owner a' 2,y T Address <br /> 19 SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR IN OTHER A0'1-70y <br /> 5. <br /> 0'LT0y5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) rn <br /> 6. 11PACKAGE TREATMENT PLANT For July 1, -June 30, 19 1� <br /> Operator Name Where Certified <br /> Plant Location r <br /> Plant Capacity P Y 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 LEANING, Chemicals Used/Amount/Mo. <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 rule and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> r� l <br /> FOR DEPARTMENT US#QNL <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Ja ary 1 &Received By January 31 ❑ July l &Received By July 31 <br /> BILLING TANGE REMIT <br /> RASE EXPLANATION $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE r G � � <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I -101 o .�, <br /> Received y Date Receipt N. Permit No. I uance Date Mailed eliv red <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2 - T KTON,CA 95201 <br />