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APPLICATION <br /> Non-Transferable, Revocable, and Suspendabl, <br /> ''ENVIRONMENTAL HEALTH PERMIT `� SEPTAGE <br /> LIQUID WASTE <br /> A{iplicat'on is hereby made to carryon busines the) ris ictional area of th San Joaquin Local Health Distric <br /> F Business Name (DBA) L- AddressoLl <br /> z Ownerl..C-r--. �_��,'T'�_A I_�� Address 345 <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. q S (n I Emergency Telephone No. d' <br /> Contractor Licence No. <br /> L Applicants Name (Print) !sI&I �LZ[ JA ALL Title Date <br /> 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. 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 Location Test Date/Time <br /> 4. ❑ SANITATION PER T t� Q <br /> Job Address/Location I �0 <br /> Owner_N Imo; vVI,S Address IJ;1 [7 h®Q_ <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT— <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No.of Units Equipment Storage/Cleaning Location(s) <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 applic 'on and that the work will be done in accordance with San Joaquin County <br /> ordinances, state and rules reg lati sthje S Joaquin Local Health District. <br /> APPLICANT'S SIGNATLh "i YA t �) � <br /> 1�r FOR DEPARTMENT USE ONL4 <br /> Fee Is Dae: ❑ ANNUALLY ❑ PER UNIT y.. PER SITE ❑ EACH ❑ Jan ry 1 8 Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BILLING MITTA_ 5 <br /> BASE EXPLANATION DATE DA REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 7l L <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Say 3 6S?117 <br /> Received by bateReceipt No. Permit No. Issuance Date Mailed oe A. <br /> I ere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1801 E.HAZELTON AVE.,P.O.Box 2005 STOCK N,CA 1 <br /> l <br />