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Applications Will Be Prod=sed When Submitted Properly completed. ue Sur, I o Sign I ne Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Sar Application is hereby made to carryon busines the j ris�Ictiona area of th San Joaquin Local ealth Dipstric f <br /> n Business Name (DBA) F W T ��L- fly t1nF Address �Cl u - � , y II <br /> Owner �[_ N RT h(�I_l Address 3,5: Q lA 7 Ll PkST^) <br /> .Firm Partners, Addresses an(d/TT lephone Numb rs <br /> 'n Business Telephone No. "I o S Emergency Telephone No. d' <br /> a <br /> Contractor Licence No. �r LL /�` _ <br /> 15 f <br /> Applicants Name (Print) �E �7`�j��--i—11�l k Title Date <br /> i Please check Applicable Category(1-7)and Fill In the Required Information / <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) w <br /> For July 1, June 30, 19 Disposal Sites <br /> —Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccnse 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 Location Test Date/Time <br /> 4. ❑ SANITATION PER T <br /> Job Add ss/Location " 71 0 Q �1 EQ�� 1�JJ `z�v <br /> Owner� I� P N t C dA dress `] <br /> ... ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLAN 4 <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER 'CC <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No.of Units Equipment Storage/Cleaning Location(.) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <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 hereby certi that I have prepared this app ion and that the work will be done in accordance with San Joaquin County <br /> ,r ordinances, state`' ,and rules reg lati s the S IJoaquin Local Health District. <br /> APPLICANTS SIGNATIL <br /> liax <br /> ^ter FOR DEPARTMENT USE ONLY r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT W PER SITE ❑ EACH ❑ Jan ry 1 &5eceived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> 6. BILLING MITTA $ AMOUNT OUE CHECKED <br /> BASE EXPLANATION DATE DA REMITTED <br /> AMOUNT <br /> FEE 7 J L <br /> ` LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Say <br /> Received by ale Receipt No. Permit No. Issuance Dale Mailed Dei ere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 209 STOCK N,CAI 261_ <br />