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APPLICATION <br /> Non-Transferable, Revocable, and Suspendab,.� <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatiolrl�i hereby matl o carry n business in the jurisdictional area of the San Joaquin Local Health District <br /> a <br /> BusinessName (DBA)_L J o. l :,�/t,�j aZ SQ ¢ Address—d3a /A' T fi �e <br /> i Owner _O wJ 13 tuy�LAddress -- <br /> 4 <br /> Firm Partners, Addresses and Telephone Numbers b"7y – aga Z ..4 <br /> b''f / ss EmergencyTele hone No. IP7h/^246(e ^. <br /> M <br /> Business Telephone No. 7' 7 P <br /> Contractor Licence No. j <br /> L Applicants Name (Print) n^ --._ --._ __ Title �� �+�es_ Date .!^/2 n9W r`; <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) --- <br /> Serial No. CAL. License No. __- CAL. Liccase 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 PERMIT <br /> Job Address/Location ��%� 7 <br /> Owner Jn 41 ' d rw �o p� / / / Address l I" --�j <br /> 91 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD )WI SEEPAGE PIT ❑ PA KAGE PLANT H <br /> ❑ PERMANENT ❑ TEMPORARY 111' NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 J <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. 11 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 6 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 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 <br /> rules and re lationr of th2.u9pn Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PrPER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 d Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE yS <br /> LESS L., <br /> PRORATION <br /> PLUS <br /> PENALTY vim' <br /> OTHER <br /> OTHER <br /> 053 d <br /> Recelve0 M Dale Receipt No, Permit No. issuarde Data Mellad Doll � <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1W1 l HAZELTON AVE.,p.O.eea xso 8T TON,CA fe1W <br /> \I R l <br />