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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> r (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicata Is hereby ade to car on b sin ss in the "risdictional area of the San Joaquin Local Health District <br /> F l/me° S l AC'A ����� �1a�` <br /> ti Business Na...'N (DBA) � Address - <br /> z Owner j1 Y*k CAA C-1he Address <br /> z <br /> Firm Partners, Addresses and Telephg.r�e.Numbers <br /> 0. Business Telephone No. X5'13 ' f Emergency Telephone No. R a <br /> Contractor Licence No.- 2413919 <br /> L Applicants Name (Print) 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 n, <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL.Liccse Renewal No. , <br /> Capacity Gal.,Weights &Measures No. l <br /> Equipment Parking Address <br /> l 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 R.S. or R.C.E. No. I <br /> Test Location i Test Date/Time <br /> 4. ❑ SANITATION PERMIT LCL/ <br /> Job AddressAocation ✓ 7 2'_ C7I1 At7-0.&1 50071 A <br /> Owner AV) C,)C tD jN f Address 5n`h e <br /> Cid SEPTIC TANK ❑ CESSPOOL ® LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT � ;l <br /> ❑ PERMANENT ❑ TEMPORARY ® NEW ❑ REPAIR ❑ OTHER J <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 / <br /> Type Construction Disposal Site 16 00 C14L :3 � �� <br /> No. of Units Equipment Storage/Cleaning Location(s) <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. 11LAUNDRY For July 1, -June 30, 19 <br /> k SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. i <br /> I hereby certify that I have prepared this application and that the'work will be done in accordance with San Joaquin County I <br /> ordinances;state laws, an nd regulations of the San aquin Local Health District. ; <br /> APPLICANT'S SIGNATURE X C <br /> - - j <br /> i <br /> A FOR DEPARTMENT USE ONLY <br /> ' Fee lS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> i - REMIT <br /> BILLING REMITTANCE $ <br /> BASE' EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE .__ 77 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br />' OTHER. F <br /> I <br /> M Received by + Date I Re&eipf No.. - _ Permit No. ' Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2609 STOCKTON,,CA 952 <br /> t <br />