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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> i APPLICATION <br /> a - <br /> (For Non-Transferable, Revocable, and Suspendable) ; <br /> t- ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Appl ica ' ishereby wide to carryon business in the jurisdictional area of the San Joa uiinn^Loca Heal th District I <br /> to Business Name (DBA) d/v �T~�� Address <br /> i Owner CH Address 12105 <br /> a <br /> Firm Partners, Addresses and ephone N mbers <br /> a. Business Telephone No. �s-a �G Emergency Telephone No. <br /> Contractor Licence No. w <br /> Applicants Name (Print) •IJ ����� r- Title' Date �� <br /> Please check Applicable Category ('14) and Fill In the Required Information <br /> 1. © PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> P <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal 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 <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. <br /> Test Location Test Date/Time N <br /> 4. W SANITATION PERMIT / 2Q <br /> Job Address/Location c�4/0o Al, 4� Pl_5 IRi1R 0 � p <br /> Owner Ru.S�Gc. e2.96F Address 696''-gLG A)S,o - <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW 0 REPAIR R .OTHER •ij!/J77 <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 /> 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. ❑ LAUNDRY For Juiy 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I <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 es and regulat'"ns of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X .-� , <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT Cl PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> - r <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> c <br /> ,Received by Date Receipt No. Permit No. Issuance Date Mailed eli Dred <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 01 E:HAZ£LTON AVE.,P.O.Boa 2009 STOCKTON, <br /> l <br />