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Applications Will Be Processed 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 <br /> Application reby Made to carry on business in the jurisdictional area of the San Joaquin Local Health District �. <br /> Business Name (D/BA) I JO h Q/�C �o f— Address er /gv <br /> aOwner, Address SA-IV S 'oz'Oyf— <br /> Firm Partners, Addresses an Telephone Numbers <br /> IL <br /> Business Telephone No. �19 Emergency Telephone No. <br /> Contractor Licence No._� i(3.2 V <br /> Applicants Name (Print) OJ O Title G r Date " <br /> Please check Applicable Category (1-7) and Fill in the Required Information C QLX7+->e Y <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. r CAL. License Renewal No. <br /> Capacity Gala'Weights & Measures No. <br /> Equipment Parking Address ` <br /> r 1 <br /> 2. ❑ PUMPER YARD-.. 1 + <br /> For July 1, .:,.-rl June 30,.19:.s <br /> No. of Vehicles Stored Il <br /> 1 <br /> 4 <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST 1 I! <br /> I R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> t Test ocati`on~ ''~ Test Date/Time <br /> 4. SANITATION PERM T _li r ` k A� 1 <br /> IC <br /> Job Address/,l=ocation �. (�U <br /> Owner _� e if`-�r4s �' Address E AS 1Q• U� g <br /> ❑ SEPTIC TANK i❑IICESSPOOL s (LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑.OTHER 'J <br /> ❑ PERMANENT ❑ TEMPORARY '' 11 NEW REPAIR SCJ ►'1H � ysC$.x 1 D <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 /> ti. ❑ PACKAGE TREATMENT PLANT ':'For July 1, -`June 30, 19 <br /> Operator Name Where Certified A <br />'F Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30,19 46' ' <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 prepafil this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules egulation the S oa uin Local Health District. <br /> APPLICANT'S SIGNAT E X � Y <br /> u FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January l &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ - REMIT r <br /> BASE �IEXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION + <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> ;i <br /> OTHER I, >• - <br /> Received by Date Receipt No. Permit No. —IftuancetDalle Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:;:;: ENVIRONMENTAL HEALTH PERMITYSERVICEs 1661 E:HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA 95 <br />