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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 /> 41NTAL 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 /> HBusiness Name (DBA) _ Address re <br /> i Owner4+J fX' -- -=r` -I r , Address rte,--ice fJ <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No <br /> Contractor Licence No. - r <br /> Applicants Name (Print) 1-r)W _,&" ' °" Title d - Date " aC- <br /> 1 <br /> Please check Applicable Category (1-7)and Fill in the Required Information JJ <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 <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. ❑ SANITATION PERMIT �.1 <br /> CA ` '4 {� � H "N. I-t=i toR�� <br /> Job Address/Location � � <br /> d(, r�- ('JE '� ,Ys�9 f 'e Address L` i` ` + -/L, I I � r I t r r <br /> Owner—.�)�. Z. if"'"` <br /> 14 SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑. PERMANENT ❑ TEMPORARY 11 NEW ❑ REPAIR <br /> ❑ OTHER S: <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction -, Disposal Site a <br /> No. of Units Equipment Storage/Craning 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 <br /> SIZE: ❑ Less Than 1,009 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 of the San Joaquin LocaLL-lealth District. <br /> APPLICANT'S SIGNATURE X - �,C, s t. <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT EI 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 REMITTEDAMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> _ OTHER <br /> � . <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed a iv/ed <br /> APPLICANT—RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E:•k1AZELTON AVE.,P.O.Box 2009 .STOOKTON,CA 95201 <br /> ri 9 <br />