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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 /> F <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> C LIQUID WASTE <br /> G Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District Q <br /> �$ <br /> Business Name (DBA) 2A - PR SIS K Address . <br /> aOwner �. . ." Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. _..�I'lel- 9&o 7 Emergency Telephone No. <br /> r-.�J Contractor Licence No. 3 <br /> Applicants Name (Print) F L-& 41eo Title 65 T/ X Date G- <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 <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 /> L 2. ❑ PUMPER YARD <br /> ` For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored 1' <br /> $ 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. C; <br /> Test Location Test Date/Time _ <br /> 4. ,Io SANITATION PERMIT <br /> Job Address/Location ;;i-}-q? S• E 5 ' <br /> Owner P-0'De4-- Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> 19 PERMANENT ❑ TEMPORARY ❑ NEW w! REPAIR ❑ OTHER <br /> h <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> r 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 /> Opeiator Name r 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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - <br /> 5 <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, and rules and regulatio of the S Joa in Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due. ❑ ANNUALLY ❑ PE UNIT ❑ PER SITE ❑ EACH ❑ January 1 a 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 /> FEE +� <br /> LESS <br /> PRORATION \ <br /> PLUS •.; r <br /> PENALTY f <br /> ` OTHER t ti• <br /> OTHER - °- <br /> k Z. <br /> --79-- a;2 ly �/7q <br /> Received by Date Receipt No. Permit No. I uance ate Mailed Delivered <br /> 4 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES' - 1601 E.HAZELTON AVE.,P.O.Boa 2009 -STOCKTON,CA 95201 ' <br /> i <br />