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w.f ' Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ` <br /> APPLICATION J1 <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAG <br /> E LIQUID WASTE <br /> Application is hereb made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) mAddress <br /> i <br /> I z Owner __ _ Address - <br /> '- 4 <br /> t 2 Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. — Emergency Teiephone No. <br /> Contractor Licence No. ti`4/ ,3 5/ <br /> Applicants Name (Print) Title Z-0-1,"4772R Date 74 <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 /> 2. ❑ PUMPER YARD i <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 <br /> 4. J4 SANITATION PERMIT <br /> Job Address/Location [//lL7 f/'� znq — - <br /> Owner � 1­6L��.ns - Address PO 43,0K 11/0 <br /> STK A) <br /> ® SEPTIC TANK ❑ CESSPOOL 0 LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> Cid PERMANENT ❑ TEMPORARY ❑ NEW 50-REPAIR JK OTHER F14-7&R 54E 1> <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 /> 5. ❑ 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 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. A 11 <br /> li 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 re lations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATU X, --- <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE Cl EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> t BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> �—� DATE DATE REMITTED AMOUNT <br /> I FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 Received by Date Receipt No Permit No. Issuan a Date Mailed Delivered , <br /> 1• - : <br /> APPLICANT RETURN ALL COPIES Tot +-ENVIRONMENTAL"HEALTH PERMITISERYICES - 1601 E.HAZELTON-AVE.,P.O.Box 2009 STOCKTON,CA 95204 <br />