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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 /> LIQUID WASTE <br /> I Appl icatio Is hereby made to/carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> H Business ame (DBA)� ,� � of C��I�ST—fid- Address , 3� (51 Mo f7 <br /> aOwner aAl J - Address <br /> J Firm Partners,Addresses ands.Telephone Number <br /> aBusiness Telephone No. 7 �� Emergency Telephone No. <br /> Contractor Licence No. 7-4"9✓5 32� <br /> L Applicants Name (Print) i <br /> "g_�-�_/-_?^tom. on g467 J!r'J Title �J?��_0 Date 12,_' 923 697 C4 <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) C>U + <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 /> 2. ❑ PUMPER YARD i <br /> For July 1, June 30, 19 } <br /> No. of Vehicles Stored i <br /> No. of Chemical Toilets Stored I <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location t Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Addr ss/Location _rc <br /> Qwner Address <br /> +SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> l ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR MOTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, June 30 19 <br /> Type Construction Disposal Sitg"'- #�T•' <br /> No. of Units Equipment�Storag e/Cleaning,Loocatsion(s) <br /> ` 6. ❑ PACKAGE TREATMENT PLANT For July 11 -June 30, 19 <br /> Operator Name WheresCertified <br /> Plant Location tt <br /> Plant Capacity No. Units Sbrved I <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 7,000 5q. Ft. !! t-- € <br /> © DRY CLEANING, Chemicals Used/Amotnt/Mo. <br /> I hereby certify that I have prepared this}application and that hejIork will be done in`accorda ce with S� Joaquin County <br /> t ordinances, state laws, and I s and regulations o e S n Jo uioc` D.tIct� <br /> t M1 _ <br /> APPLICANT'S SIGNATURE:X _ _... . ,.:. _ _. �... .:. <br /> "0 6" <br /> l - > -fit FOR DEPARTMENT US ONLY . <br /> Fee Is Due: ❑ ANNUALLY .,. ❑'PER UNIT ❑ PER SITE El EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ti REMIT <br /> BILLING REMITTANCE $ <br /> k BASE EXPLANATION PATE PATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEEO <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by- Datle I Receipt No. Permit No. Issuarif Da Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO! ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />