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ApplicationsWill 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 /> Applicati R is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> FB Business Name (DBA) ALPI-) SC_i-II& <br /> J.- <br /> Owner 11 �2 � a dVDAAddress <br /> 4 Scl� <br /> 1 Firm Partners, Addresses and Telephone Numbers Address 18`�T?e� � 11/7 <br /> CIL <br /> Business Telephone No. 823csf - <br /> -_Jj Contractor Licence No. Emergency Telephone No. <br /> L Applicants Name (Print) 1t <br /> Please check Applicable Category ( Requiredl In the Title '3 Date i 1 <br /> i• ❑ PUMPER VEHICLE PERMIT REGISTRAITION (FOR EACH VEHICLE) <br /> 1 For Jul 1, <br /> July June 30, 19 <br /> Description(Make/Yr., Color) Disposal Sites <br /> Serial No, <br /> I Capacity Gal. CAL. License No. CAL, License Renewal No. <br /> , Weights & Measures No, <br /> Equipment Parking Address <br /> Z• ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> f No. of Chemical Toilets Stored <br /> 3. 0 PERCOLATION TEST <br /> R.S. or A.Ml.N�ame <br /> Test Loca4lion �5 r9Y f�p}�� R.S. or R.C.E. No. <br /> oTtD <br /> 4• ❑ SANITATION PERMIT Test Date/Time <br /> Job Address/Location <br /> Owner <br /> ❑ SEPTIC TANK 13CESSPOOL' El LEACHING FIELD res❑ s <br /> El ❑ TEMPORARY ❑ NEW SEEPAGE PIT ❑ PACKAGE PLANT <br /> �• ❑ CHEMICAL TOILETS For July -June 30, i9 1, ❑ REPAIR 13OTHER <br /> Type Construction IDisposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. 1:1PACKAGE TREATMENT PLANT FoiI 1, -June 30, 19 <br /> Operator Name e <br /> Plant Location Where Certified �CS <br /> Plant Capacity <br /> 7. 13LAUNDRY For July 1, -,lune 30, 19 No, Units Served <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> } <br /> 1 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, an es n ulatlon&gf the San Joa n Local Health District. <br /> APPLICANT'S SIGNATURE + <br /> FOR DEPARTMENT USE ONLY y <br /> Fee Is Due: ❑ ANNUALLY PER UNIT ❑ PER SITE EACH ❑ January 1 &Received By Januar ' <br /> y 31 <br /> ❑ Jufy 1 &Received By July 31 1! <br /> BASE EXPLANATION BILLING REMITTANCE <br /> $ REMIT <br /> DATE a <br /> DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS 1 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER + <br /> ��Received by Dat <br /> ., eceipl No- Permit No. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH pERIUIT/SERVICES Issuance Date Mailed Delive d <br /> 1601 E.HAZELTON.AVE.,P.O.Boa 2009 STOC TON, 95201 - <br />