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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is her by made to carry on business in the jurisdictional area of th San Joa uin Loral Health District G �� <br /> Business Name (DBA) N �, �t��95�idCff _ __ Address_ o 1daJ1 1,9F D/��✓�—O ✓ C`4 _ <br /> z Owner_ 514 1-1 L_ Address_ <br /> t <br /> J Firm Partners. Addresses and Telephone Numbers <br /> aBusiness Telephone No. 09_-3 G _ Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) ___A L--, N4/4h� Q C'ff L' (' /1- Title w f�� Date�.9 <br /> Please check Applicable Category (1-7) and Fill in the Required Informafion <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 0 <br /> For July 1, June 30, 19 Disposal Sites _ 1 <br /> Description(Make/Yr.,Color) <br /> Serial No. _ CAL. License No. _CAL.Liccise 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. A SANITATION PERMIT <br /> Job Add ress/Locati n <br /> Owner �, ��•_��'/��/� �. Address G, d / /✓O/t��rDA��'.�/ 9i3_ _ <br /> M SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ 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) __— _ _J <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19—_ _1Z <br /> Operator Name __._ _ ._.— Where Certified _ 41, <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/M0. —.. <br /> I hereby certify that I have prepared this application and t the work will be done in accordance with San Joaquin County <br /> ordinances,slate laws,a rule a regulations of the a J aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE El EACH ❑ January 1&Rme ved 9y January 31 ❑ July 1 &Recervad By July 31 <br /> BILLING REMITTANCE j REMIT <br /> BASE EXPLANATION AMOUNT DUF CHECKED <br /> DATE DATE REMITTED <br /> �{Si ys o <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS \ <br /> PENALTY d <br /> OTHER <br /> \0 <br /> OTHER <br /> AP <br /> Received by .Date Rrcei pt No. Permil NU Issuance 071te �Ro,�IMQ <br /> ivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AV . CKTON,CA 95201 <br />