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Applications Will Be Processed When Submitted Properly Completed. BeSureTo Sign TheApplication. <br /> �a APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> U) Business Name (DBA) A. ' -g��Sf� yQ� S�e1, Address f4 LSaX / a�y ar" eTiU `�1 � <br /> I- <br /> 2 Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. - Emergency Telephone Na. <br /> Contractor Licence No.�2 r� 3 `/3 <br /> LApplicants Name(Print) t J> d Title Date <br /> Please check Applicable Category(1-7)and Fill in 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. Licc^se Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address 4, <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored A <br /> No. of Chemical Toilets Stored I <br /> 3. ❑ PERCOLATION TEST C <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. Jq SANITATION PERMIT <br /> Job Address/Location <br /> Owner 7`J m <br /> 0-774,f-e— 9E"'V _ Address g/a wei-Fe '!r6 5 7 <br /> Dd SEPTIC TANK ❑ CESSPOOL LEACHING FIELD Of SEEPAGE PIT ❑ PACKAGE PLANT <br /> O(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) i <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. 13 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 /> 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, and rules and regulations e a 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 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUF CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1 <br /> �779 <br /> --75b 171 �^ <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed beliv.pdD- <br /> -APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON�`VE.,P.O.Box 2009 STOClItTON,C 952010 7. <br />