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�0 Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> to ✓ f' APPLICATION <br /> _ r (For Non-Transferable, Revocable,and Suspendable) <br /> " ✓` ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> A!9 1 l Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> HBusiness Name (DBA) Address�� <br /> z Owner Address <br /> J Firm Partners, Addresses and Telephone Numbers 0d <br /> a. Business Telephone No. �G s''�97/ Emergency Telephone No. C2 <br /> Contractor Licence No. !5"3 Sg33 <br /> a Applicants Name (Print) F�"Y?� /n 99ab Title ea",VA!r-e Date 10-2-3 -20 ^� <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 <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. 0 SANITATION PERMIT <br /> Job Address/Location t 31 9 Al, .411440A/ D,0e' 5����i+✓ ��r��"� ^' ���� � -- <br /> Owner IA:F & 7-- Address .*4.0-/ <br /> Of SEPTIC TANK ❑ CESSPOOL LEACHING FIELD QV SEEPAGE PIT ❑ PACKAGE PLANT S <br /> PERMANENT ❑ TEMPORARY ral 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 <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 application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations a San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X _ <br /> e) <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 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS `{ c� <br /> PRORATION <br /> PLUS t O <br /> PENALTY i !! <br /> OTHER € ✓lam <br /> a <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date (',Tiled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE. ox 2009 STOCKTON,CA 95201 <br />