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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 /> 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 /> UF Business Name (DBA) 45'4) Address Zf /IYA�LE T .S��e D.✓ <br /> z Owner Address <br /> C <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. ���9 7/ Emergency Telephone No. _ X <br /> Contractor Licence No. /s3 .S'7_3 �1 <br /> Applicants Name (Print) F4-t1,Y� U1010� Title c5�1 Date S-1i1"-8Z t <br /> Please check Applicable Category (1-7)and Fill in the Required Information C1 1 <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. Liccnse 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 <br /> 4. J0 SANITATION PERMIT <br /> Job Address/Location 106 SS N, AL1�iNE �e� Ld�i <br /> Owner 1ZaA/At D Z)- r tl AJ/I Address es-T <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD Wr SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY RR NEW ❑ REPAIR ❑ OTHER SIN <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 July 1, -June 30, 19 a <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 application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations o n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> o <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT � <br /> Q <br /> FEE <br /> LESS 4 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER C <br /> Received by Date Receipt No. Permit No. I Iss ance D Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELT .,P.O.Box 2009 STOCKTON,CA 95201 <br />