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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> I (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> UQUID WASTE <br /> F Applicati s hereby ma to car on business in the'urisdictrignal area of the San Joaquin CBI Health District <br /> y Business Name (DBA) �DT_ Q 01 4;P 5Z56V/CG Address dS� oLC ��11P7 R <br /> i a Ownert�j iF�t G'rr _ Address <br /> Firm Partners,Addresses and Telehone Numbers _ <br /> �_ �•�� l <br /> CL Business Telephone No. _ _____ _ Emergency Telephone No. <br /> Contractor Licence No. �j�1 <br /> Applicants Name (Print) �� <br /> , �uJ` Title �ST DaleL�_ <br /> Please check Applicable Category(1-7)and Fill it the Required Information <br /> 1. ❑ 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 /> k 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored a <br /> No. of Chemical Toilets Stored ` <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.G.E.No. i <br /> Test Location Test Date/Time _ _ p <br /> SANITATION PERMI <br /> J � I <br /> Job Address/Location_. � _ d <br /> Owner�hl� t,�1N I 1'714'44F& Address <br /> i (SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT f <br /> PERMANENT ❑ TEMPORARY PrNEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> iType Construction _ Disposal Site <br /> No.of Units Equipment Storage/Cleaning Location(s) f <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 y. <br /> Operator Name _ Where Certified <br /> Plant Location I i <br /> Plant Capacity I No. Units Served _ <br /> 7. ❑ LAUNDRY For July 1. -June 30,19__ <br /> I SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. . <br /> . I <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, a ules and reg ations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X � t i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due; ❑ ANNUALLY ❑ PER UNIT ❑ PER SII L ❑ LACH ❑ January 1&Received Hy January 31 .❑ July 1&Received fay Juiy 31 <br /> REMIT <br /> 1 BASE EXPLANATION BILLING REMITTANCE 5 AMOUNT DUE CHECKED <br /> DATE - DATE REMITTED AMOUNT <br /> FEE �r <br /> LESS <br /> PRORAI ION <br /> PLUS .} -- - -- - - ---- - ,li <br /> PENALTY " <br /> I OTHER <br /> OTHER <br /> - _ _ <br /> I Received by Date Racelpt No. Permit No - Issuance ate Mailed Delivered <br /> II APPLICANT—RETURN ALLCOPIESTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20 STO K CA 05201 <br />