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Applications Will BeProcessed 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 3 Z- <br /> Appl kation i ab a cara on business in the jurisdictional area of the San Joaquin Local Health District <br /> wBusiness Name (DBA d G �C Address <br /> z Owner r C Address—�� — <br /> C r <br /> J.Firm Partners, Addresses and Telepphhone_lumbers <br /> ka Business Telephone No. yY� o� Emergency Telephone No. <br /> Contractor Licence No. C <br /> _ Ala Title � Date�/�����, L -� <br /> Applicants Name (Print) <br /> I Please check Applicable ategory (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) r_.._ - .newal No. - <br /> Serial No. CAL. License No. .: CAL.License Re <br /> t Capacity Gal.,Weights &Measures.No. <br /> j Equipment Parking Address <br /> 2. ❑ PUMPER YARD € <br /> For July 1, June 30, 19 t �01 �I <br /> No. of Vehicles Stored 'No. of Chemical Toilets Stored . tF <br /> 3. ❑ PERCOLAi"10_N TEST <br /> + R.S. or R.C.E. Name R.S.or R.C.E. No. I <br /> Test Location t Test bate/Time" <br /> 11111 0' 7�F <br /> 4. XSANITATION PERMITAl <br /> FY Job Address/Location eC. O "( <br /> Owner ff .. Address -3 �-- �. �%S 94 5 a 17a—AZ—,Z <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACIiING 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) + <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> - Where Certified <br /> Operator Name a <br /> Plant Location <br /> Plant Capacity <br /> No. Units Served - <br /> � '_g,a � <br /> 7. ❑ LAUNDRY. For July 1, -June 30,;19 C <br /> ti <br /> SIZE: ❑ Less Than71,000 Sq. Ft., ❑ More Than,1,000 Sq-Ft— <br /> t � <br /> ❑ DRY CLEANING, Chemicals Used/Amourit/,Mo. <br /> - ' <br /> yr <br /> F a � <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, and regulations f the San aquin Local Health District. <br /> OOF <br /> APPLICANT'S SIGNAT E X <br /> 2 L <br /> R,DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 13 January 1 &Received By January 31 El July 1 &Received By July 31 <br /> ' - - REMIT <br /> BASE t; AN BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> fff DATE DATE REMITTED AMOUNT <br /> FEE r _ - <br /> LESS <br /> i PRORATIONPLUSPENALTYOTHER ,FOTHER s- x ;e, <br /> -zL <br /> Received by Date - Receipt - - Permit No. ,£,.issuance Date Mailed Delivered <br /> - 'APPLICANT—RETURN ALL COPIESTO: ENVIRONMENTAHEALTH PERMIT/ ES � 16g1 E•HAZEL E-�P�Bbx 2D09�;STOC�T��A 9520t <br />