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Applications Will Be,Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> - APPLICATION <br /> (For Nan-Translerable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> p LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> j N Business Name (DBA) A ,SAl, (gi.✓SriC-c✓ 5-- 77/oA/ Address 47V6kZ22/ <br /> zOwner Address <br /> " J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No.- ��' s ----9-71 Emergency Telephone No. <br /> �— <br /> a <br /> Contractor Licence No. / SR•-3 <br /> LApplicants Name (Print) .oe� Title d ✓ 'i�6/� 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 L(ccnse Renewal No. <br /> Capacity Gal., Weights &.Measures No. <br /> Equipment Parking Address <br /> I 2. ❑ PUMPER YARD <br /> For July 1. June 30, 19 <br /> No. of Vehicles Stored <br /> No- of Chemical Toilets Stored <br /> w <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.G.E. No. <br /> Test Location Test Date/Time <br /> I 4. (V SANITATION PERMIT O <br /> Job Address/Location le-3492— CAPe lUyaoO �'�( 57z' �rtT�✓...__ (}� <br /> Owner —_ 15DNALr7 m-a FF- C— Address Dn •a3 F,F4,I &lelaD Sro�.�rax/ Q <br /> SEPTIC TANK 11 CESSPOOL LEACHING FIELD Z SEEPAGE PIT ❑ PACKAGE PLANT <br />? PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER ' <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> r Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> _6.,,.E PACKAGE.TR_EATMENT PLAN_ T For July 1,_June 30, 19 r _ <br /> + <br /> .6.-.El <br /> Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 C <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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 rules and regulation O an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT -❑ PER SITE C3 EACH ❑,January 1 &Received By January 31 [].July 1 &Received By July 31 <br /> i7 <br /> REMIT 1 <br /> BILLING REMITTANCE $, <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE LESS <br /> PRORATION <br /> PLUS / <br /> PENALTY <br /> OTHER <br /> OTHER - <br /> I <br />`- Receive y e Date Receipt No Permit No. Iss ante oate Mailed Delivered <br /> 4 APP ANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVLCES 1601 E.HAZEL.TON AYE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> I .� <br />