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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 SEPTAL <br /> iLIQUID WASTE <br /> ' Applicat' n hereby m@de to carry o�usiine s i the juris tional area of the San Joaquin cal H�lth District <br /> y Business Name (DBA) /�1�1�Gl �C-s ,� .jC1� bO4e Address— <br /> 'Tl <br /> ddress <br /> a Owner Tf ✓`1 l-/�R C�rJ C Address <br /> Firm Partners, Addresses and Tph ne Numbers - <br /> 5. Business Telephone No. 2 �' IV Telephone No. <br /> Contractor Licence No 24/3—T; <br /> L Applicants Name (Print) / 'M �l(ZG CLQ Title Date <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. Lice.-,se 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. i SANITATION PERM�IT, p� -r,� <br /> Job Address.4Lwation I iquS Rid <br /> Owner J I m W RIeig Address 'erne <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ 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/Cleaning Location(s) `+ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 •i <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. <br /> I hereby certify that I have prepared this applicatio and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,_2jles anddrpregul ns of Joe San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ' <br /> oe -311-t m® <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br />. AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS \ <br /> PENALTY <br /> OTHER <br /> OTHER <br /> yyi 6 7 31 qF o <br /> Received by Date I Receipt No. Permit No. Istuancd Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />