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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 w SEPTAG� <br /> LIQUID WASTE <br /> t: Application is he�rreeb ma to carry on business in the jurisdictional area of t�j Soman oaquin Local Health District " <br /> yBusiness Name (DBA) -� FRSs ' —_ -• Address.~".; � 5 � � Z� <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. �9G a-7 Emergency Telephone No. 4 <br /> Contractor Licence No. <br /> Applicants Name (Print) I`�A]Lo w "R. -Sims —Title 4.. Date <br /> Please check Applicable Category (1-7) and Fill in the Required information <br /> OU # <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> i <br /> For July 1, June 30, 19 Disposal Sitesbi . <br /> Description(Make/Yr., Color) <br /> y' <br /> Serial No. CAL. License No. CAL. License Ranewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address ;. :; <br /> 2. ❑ PUMPER-YARD <br /> For July 1,—' .June 30, 19 <br /> No. of Vehicles Stored _ f <br />` No. of Chemical Toilets Stored t <br /> i 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Loo ton Test Date/Time <br /> 4. L7 SANITATION PERMIT <br /> Job Address/Location 1 4 7) I" .. <br /> O,wnner A S Address <br /> L� SEPTIC TANK ❑ CESSPOOL 0 LEACHING FIELD E PIT PACKAGE PLANT <br /> 13 PERMANENT ❑ TEMPORARY) ffNEW 4:ZPAIR ❑ OTHER - <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 si <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 tr <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 . = ; <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., " ❑ More Than 1,000 Sq. Ft. • <br /> it ❑ DRY CLEANING, Chemicals Used/Amount/Mo. . -. R <br /> r <br /> I hereby certify that I have prepared this application and that the:work will be done in accordance with San Joaquin Countyl <br /> ordinances, state laws, rules a regula oft an J" aquin Local Health District: <br /> APPLICANT'S SIGNATURE ' <br /> a �. . <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> •i,� i l + - <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 11 PER SITE, ElE ❑ January 1 &Received By January 31;" ❑ July 1.8 Received By July 31 <br /> ,REMIT i <br /> BASE EXPLANATION BILLING REMITTANCE $ ,AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS G I <br /> PRORATION <br /> PLUS J +; t s <br /> PENALTY i <br /> - OTHER - - <br /> - i <br /> 1. OTHER °. <br /> ad 8 <br /> Received by Date – . Receipt No.; Permit No; irjunnce pate a Mailed Delivered <br /> a <br /> APPL-iCANT—RETURN ALL COPIES TO: ENVIRONMENTAL-HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />