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y6 Applidations Will Be Processed When Submitted Properly Completed. Be SureToSign TheApplication <br /> APPLICATION <br /> (For.Non-Transterable, Revocable,and Suspendable) I <br /> _ ~ ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> = LIQUID WASTE <br /> Application is hereby made to•carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> W , <br /> Business Name (DBA) Q S� � ,g =a4 Address ;x°r W A t_ = <br /> z Owner Address <br /> 4 ' <br /> J Firm Partners, Addresses and <br /> �Telephone Numbers <br /> a. Business Telephone No. �6ym: _-T-97/ Emergency Telephone No. <br /> Contractor Licence No. IS, 3 <br /> L Applicants Name(Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH,VEHICLE) v t <br /> For July 1, June 30, 19 Disposal Sites ~` 4' <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 r <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 r <br /> 4. 1a.1 SANITATION PERMIT <br /> Job Address/Location ST�Gr a�t1 <br />` Owner ADWA S,7-4--il .—," Address 114/ Sr-AA✓PLVOCA Ag xE <br />` ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD X SEEPAGE PIT ❑ PACKAGE PLANT <br /> JZ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/C leaning-Location(s) �— <br /> 6. ❑-PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified Y <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 /> I hereby certify that I have prepared this applicatio that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of he Sa Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X - <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received.By.January 31 ❑ July I &Received By July 31 <br /> ,.BILLING REMITTANCE <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> rn ', Q <br /> FEE `� -/IS S <br /> LESS <br /> PRORATION <br /> PLUS 5014,� <br /> I PENALTY <br /> OTHER <br /> OTHER <br /> k Received by Date Receipt No. Permit Na. Issua-=- n Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH.PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />