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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION `a <br /> (For Non-Transferable, Revocable,and Suspendable) , <br /> ENVIRONMENTAL-'WEALTH PERMIT SEPTAGE <br /> LIQUID WASTES <br /> Application is hereby made to carryon busi ass in the jurisdictional area of the 5 Joaquin Local Health Di <br /> y Business Name (DBA) r4 ry S Y <br /> iOwner Address strict <br /> Address f Gk <br /> no Firm Partners, Addresses and Telephone Numbers ' <br /> a- Business Telephone No.. 0 ` <br /> Contractor Licence No. Emergency Telephone No. <br /> LApplicants Name (Print) <br /> y ,Title <br /> Please check Applicable Category.(1-7)and FillInthe Required Information Date S"' — $ 7 <br /> 1- 1:1 PUMPER VEHICLE PERMEG <br /> IT REGISTRATION (FOR EACH VEHICLE) F ' ° <br /> For July 1, June 30, 19 <br /> Description(Make/Yr., Color) Disposal Sites �� + <br /> Serial No. - <br /> i <br /> Capacity. CAL. License No.' CAL. License Renewal No. <br /> Gal., Weights & Measures No. <br /> Equipment Parking Address � .. <br /> 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 <br /> Test Location R.S. or R.C.E. No. f <br /> 4. 19 SANITATION PERMIT I Test Date/Time <br /> Job Address/Location d 7,.$— <br /> Owner &,'I �' ��S * <br /> ❑ SEPTIC TANK ❑ CESSPOOLJ� Address —5 -- 1 <br /> ❑ <br /> LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> E3 PERMANENT ❑ TEMPORARY . <br /> 5• ❑ CHEMICAL:.TOILETS For July 1,-June 30,.19 " � � REPAIR ❑ OTHER <br /> Type Construction <br /> No. of Units Disposal Site. <br /> Equipment Storage/Cleaning Location(s) Q <br /> S• C1 'PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name (�� I <br /> Plant Location Where Certified "1 <br /> Plant Capacity a a <br /> 7. ❑ LAUNDRY For July , -June 30, 19 1No.-Units Served <br /> _. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq.Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 9lr>+ 9siRt risT'€ 1' a {g� <br /> f;FCh Rlarne,z5, + tisa `�Etc rtfn <br /> t3 tjr jrts�-_ t^11€tisn t k3d+Yt°! '{rj t gtSRrf6ffdNief,o{f91eV14Y€;`j+SYW,4lff�l(�Il.,(38ftfi}t��($5�l�et�ri�lflf)9f�f�1�71f1 R <br /> ` if:�h?Y�g }S Y+P! - '� -'t+1Wl 1 Y i^6a.3 igx�+ n; . .f r,+3 f'a.i�r�`!ta ! <br /> amp 14€Y I O;Iss�7 19'Nrrr f�0 ml�erasat�n l rima ��' e;lffy'hat"'ll3S x'16011 <br /> , ! <br /> �l C, Irrrrt�ia- ;t�tft4rjnance.of ti?e work for WIligh lhil prinj3 ila JAp- <br /> I hereby certify that 1 have"'prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and ti <br /> regulao _ of the S oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X 4 <br /> ' « FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITEt❑ j <br /> ❑ EACH iJanuary 1 &Received By January 31 ❑ July 1 &Received By July 37 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE r AMOUNT <br /> LESS T <br /> PRORATION - .. �• i.# <br /> PLUS <br /> PENALTY �. . <br /> 4 <br /> OTHER <br /> OTHER i <br /> 5-a6- - <br /> Received by8a <br /> ... _ { Date Receipt No. Permit No. <br /> Issu rice Date Mailed Delivered <br /> ' APP;SCANT—RETURNALL�'COPEES-TOi1' ENVIRONMENTAL HEALTH pERM1TlSERVICES' <br /> _ 1601 E,HAZELTON A .Box 2009 STOCKTON;CA 95201 <br />