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�rr••��••••••a ••••• uo �•uceaavu vnen auunuueu rropeny L.ompleteo. lie sure to 519n 1 ne Application. <br /> APPLICATION <br /> `% br Non-Transferable, Revocable,and Suspendab%fol <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicat }is hereby me�to�carry usir�ss' the jurisdictional area of the Be Joaqui ocal Hea th Distr'ct <br /> Business (DBA) y{� /yiY� _ LAddress <br /> iOwner p ley $, £�f — Address — r r r <br /> Firm Partners,Addresses and/7elpph5ine N bens 7 <br /> IL Business Telephone No._�1? 3E .�f'-3y''mergency Telephone No.— —3--J <br /> Contractor Licence No. O S <br /> I Applicants Name (Print) C � Title 1''J LJt.)/l�l� Date dC10��g d <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. El 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. 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 C <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. L <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Add r s/ c tion <br /> Owner agacit, Address /7 _ T <br /> I'SEPTIC TANK ❑ CESSPOOL C9 LEACHING FIELD 21SEEPAGE PIT ❑ PACKAGE PLANT \v1 <br /> 12 PERMANENT ❑ TEMPORARY 2 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 certify that I have prep ed this ap cation and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, and nd regul o he San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &R%elved By January 31 ❑ July 1&Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS (/ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> � ItSa <br /> 7!3 <br /> Received M Date Receipt No. Permit No. Issuance OA <br /> Date Mailed e e <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.a 3005 STOCK ON,CA 301 <br /> y79 �� d <br />