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E rApplications Will Be Pfi+ised When Submitted Properly Completeo.ne Sure I u 91v,1 r «Rrr•�•^••- <br /> 1 APPLICATION <br /> ' FEB 14 1980 (For Non-Transferable,Revocable,and Suspendable) { <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SEPTAGE <br /> - -J SAN JOAQUIN LOCAL LIQUID WASTE f <br /> NEA T ft ' egTR��b <br /> Appllcatl Is e e a t car on business in the jurisdictional area of the San Joaquin oval Hea th Di rlc ,r3f I <br /> Business Name{DBA) Address i. <br /> �z Owner <br /> Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> LJ Emergency Telephone No- A <br /> F Business Telephone No. <br /> -I Contractor Licence No. a Date <br /> r L Applicants Name (Print) Title <br /> Please check Applicable Category (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) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal ,Weights&Measures No. <br /> r--- Equipment Parking Address <br /> + 2. ❑ .BUMPER YARD <br /> For Ju y 1, Ws June 30, 19 <br /> No, of Vehicles Stored <br /> No.of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S.or R.C.E.No. <br /> R-S.or R.C.E.Name W <br /> TTest Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT �rA��J <br /> Job Addre s/Locat' n <br /> Owner - Address <br /> C�YSEPTIC TANK ❑ ESSPOOL G�'LEACHING FIELD ❑ SFEPAGE PIT PACiAGELAI�iT <br /> 1C rPERMANENT ❑ TEMPORARY GVNEW ❑ REPAIR ❑ OTHER <br /> O <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 la <br /> Type Construction Disposal Site x <br /> rNo.of Units Equipment Storage/Cleaning Location($) 11` <br /> S. 13 PACKAGE TREATMENT PLANT For July i, June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> F Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19_ <br /> SIZE, 13Less Than 1,000 Sq. Ft., 13More Than 1,000 Sq. Ft. <br /> i ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i 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,an rules and regulatlovy of t e San Jo uin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> F1 - ' V <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> �� Fee 1s Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 3 Received By January 31 ❑ July t 8,Reaelvad Ry,1uly 31 <br />` REMIT <br /> SASE EXPLANATION BILLING REMITTANCE -AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT- <br /> I <br /> FEE <br /> 10+ <br /> �} LESS <br /> PRORATION m� <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ti <br /> OTHER <br /> I � <br /> r <br /> Permit v. Issuance Date Mailed livers <br /> Received by Date Receipt No. • <br /> STCGI(T N,CA <br />, <br /> APPLICANT—RETURN ALL COPIESO: ENVIRONMENTAL HEALTH PERMILISERYI�ES1601 E.HAYELTON AVE.,P.O.eoa IMt___ � <br />