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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ""'Teor Non-Transferable, Revocable, and Suspendab* <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatyon is hereby made to carryon busines the I risglctlonal area of th San Joaquin Local Health District <br /> Business Name (DBA) L F= Er W A�t"` flc h Address <br /> r <br /> z Owner LF 17— \w I A LT Address <br /> Firm Partners, Addresses an4 Tglleephoone//Numbers 1 <br /> .Business Telephone.No. �� tO Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) �„ � (� (�jL� Title Date <br /> `Please check Applicable Category (1-7) and Fill In the Required Information <br /> I. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <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 /> LEquipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> LNo. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> CTest Location Test Date/Time <br /> 4. ❑ SANITATION PERI <br /> Job Address/Location�.� �.\ <br /> Owner � ) �y1„S I Address `-1 D 0 0 1k <br /> � <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT b PACKAGE PLANT e, <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER Jae <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> L <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> FF,, 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> lant Location <br /> Plant Capacity No. Units Served <br /> ((� 7. ❑ LAUNDRY For July 1, -June.30, 19 <br /> L.SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> DRY CLEANING, Chemicals Used/Amount/Mo. <br /> L <br /> I hereby certi that I have prepared this applic ion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state and rules reg lati s the S Joa(q�uin Local Health District. - <br /> LLICANT'S SIGNATI ;� , \ Ki��_� <br /> FOR DEPARTMENT USE ONLYI <br /> t Fee Is Due: ❑ ANNUALLY ❑ PER UNIT yt PER SITE ❑ EACH ❑ Jan ery 1 8 ReceivedBy January 31 ❑ July 18 Received By July 31 <br /> 1 BILLING MITTA S REMIT <br /> it BASE EXPLANATION DATE DA E�1 REMITTED AMOUNTDUE CHECKED <br /> AMOUNT <br /> FEE 7� L <br /> 1 LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER — <br /> OTHER <br /> 3 6 <br /> R I ed aY —Dal-1 R Ipl No. Permit No. Issuance Date MailedD' erive,e <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box Meg STOCK N.CA 9 201 <br />