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I ApplicatioisWill Be ProcessedWhen 5ubmltted Properly Gompletea. ue bure Io algn Ine PLppitcauon. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT, SEPTAGE <br /> LIQUID WASTE a <br /> Applica is hereby made to carry on business in the jurisdictional area of._the:.San Joaquin Local Health District <br /> In Business Name (DPA)r 11T ��TcIN cSC��l Address <br /> z Owner—Ml Fkc '( Address � <br /> a AC , <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. �� a+'C Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) A ��Ith, <br /> `lr Title e�5�- – Date <br /> Please check Applicable Category(1-7)and Fi1Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, .I June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) j <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> f 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 t R.S, or R.C.E. No. <br /> Test Location 1 Test Date/Time W <br /> 4. 15�SANITATION PERMIT VJ <br /> I Job Ad ess/Location Sit l it tz� fn �� <br />`t Owner. div ` <br /> +r LE 61i, V Address C C/; At <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD J0 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ® PERMANENT�iI ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER { <br /> 5, ❑ CHEMICAL TOILETS For July 1;.-June 30, 19 `S <br /> i n Dis osal Site�-z <br /> Type e Construct o P <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name f 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_-S4. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/14o__ i <br /> r <br /> } 60- <br /> 1q, <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, r and regulations of the Sa Joaquin Local Health District. <br /> 3 F: <br /> APPLICANTS SIGNATURE X s <br /> I <br /> .. <br /> FOR DEPARTMENT USE ONLY. <br /> .�i;�,f s w w ". <br /> r; t Fee 15 DUe:,❑ ANNUALLY ❑ PER UNIT PER SITE •❑ EACH © January 1 8 Received By January 31 % ❑ July 1 &Received By July 31 _ <br /> - REMIT . <br /> .jI BILLING•> - -REMITTANCE $ AMOUNT DUE CHECKED <br /> t• - BASE `EXPLANATION - DATE DATE 'N . 'REMITTED 3 '" <br /> s �. AMOUNT <br /> % -FEENf_ k <br /> LESS <br /> PRORATION Lq,4 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> l OTHER 4 <br /> AMS <br /> Received by ., Date Receipt No. Permit No. lfuanqb Date Mailed alive <br /> (CANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVIC£S - 1601 E HAZELTON AVE.,P.O Bo:2009 STOC TON,G 5201 <br />