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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The.Application. 1 <br /> APPLICATION ' <br /> (For Non-Transferable,Revocable,and Suspendable) > SEP�TAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE j <br /> Application is hereb made to carry on business In the jurisdictional area of the Sart Joa uln Local Health District ftp <br /> -- -n <br /> Business Name (DBA) <br /> Address �� � <br /> z Owner <br /> Address ;. <br /> a , <br /> 2 Firm Partners, Addresses and Telephone umbers <br /> 10, <br /> Business Telephone No. 4Z - - Emergency Telephone No.a. - - <br /> I ;Contractor Licence No. <br /> S—q- fir, tit '�jt M Title ��"i4!' l� Date <br /> Applicants Name(Print)— _ r----- - <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) j <br /> For July 1, June 30, 19'.= = Disposal Sites �! <br /> '[fie§cription(Make/Yr:'Color)_- - <br /> Serial No. CAL-'L-Icense No = CAL. License Renewal No. �.r <br /> �1 ` ! <br /> Capacity . _ # dal.,We_Ights,&A"Ilif'asures No. <br /> Equipment - <br /> Parking Address, <br /> 2. ❑-PUMPER YARD <br /> For July 1. June 30, 19 r <br /> r f <br /> No. of Vehicles Stored �- <br /> No. of Chemical Toilets Stored t 4 <br /> 3. ❑ PERCOLATION TEST ii I <br /> R.S. or R.C.E. Name i ; R.S.or R.C.E. No. <br /> Test Location <br /> I i est Date/Time t <br /> 4, 9'1—ANITATION PERMIT.'-1 v 1 <br /> t Job Addre s/Location 1 <br /> Owner 12�V� _ <br /> tJDDV P ' Addielg!. � A '� <br /> C�LEACHING FIELD" I�SiEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ SEPTIC TANK ❑ CESSPOOL r <br /> l €RMANENT ❑ TEMPORARY ❑ NEW { {P�RPAIR ❑ OTHERS <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ' 4 <br /> ' Disposal Site `•r` - <br /> Type Construction <br /> No. of Units Equipment Storage/Cleaning.ocation(s) <br /> i <br /> 6. ❑ PACKAGF_'TREATMENT PLANT' For JuTy 1;_' June 30, 19 s f <br /> Where Certified <br /> Operator Name <br /> r - <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. I } <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo, ` . •x. <br /> 1 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,a s and redulati of the S aquin I He th District. f' .7 <br /> 1 A <br /> APPLICANT'S SIGNATURE X - T <br /> {I . FDR nEPARTMENT IUSE ONLY'.' a i z:•� -.� v <br /> sFCC IS DUe' ❑•ANNUALLY _ PER UNIT ❑ PER 517E ❑ EACH ❑ January 1 $Reserved BY January 31 ❑ July i Received By Jy my L <br /> y REMIT <br /> •BILLING—.. _REMITTANCE .. $.�� � AMOUNT DUE •� CHECKED <br /> •�Ek¢LANATIONI bA`rE - 'DATE ""R£MITTEOtiy AMOUNT L <br /> rl 1 FEE <br /> S <br /> \ i LESS F <br /> PRORATION <br /> PLUS t. r <br /> PENALTY I: <br /> OTHER f <br /> /Ti OTHER13 <br /> f <br /> Rece� t No. Permit No. SS Ge 0 e Mailed Delivered <br /> P <br /> Received Dy Date ``;N, <br /> t. .-. APPLICANT i RE?URN ALL COPIES.TO:--ENVIRONMENTAL HEALTH P_ERMITISERVICES - '^' 1601 E. AYE.,P.O.Box 2009 .6TOCKTON,CA 85201 <br />