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Applications Will Be Processed When Submitted Properly Completed.-Be Sure To Sign The Application. <br /> APPLICATION <br /> W (For Non-Transferable, Revocable,.and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT f SEPTAGE <br /> Y LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> N Business Name (DBA) ,��)OAO .g '7d u' Address <br /> z Owner Address <br /> Q <br /> J Firm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone No. 7/ Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) FLV yL> Title Ate;r_ 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. Liccnse Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address. <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 5 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST 3 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. - <br /> Test Location Test Date/Time <br /> 4. X SANITATION PER``M��IT�-� <br /> JobA'ddress/Location !/I <br /> Owner 7UA e ,6 L (9" -14< Addres�s! <br /> 11 SEPTIC c <br /> SEPTIC TANK CESSPOOL 04 LEACHING FIELD SEEPAGE PIT. ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW Iff REPAIR.. '❑ OTHER K <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. ti <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I <br /> 1 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 e.San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> { <br /> FOR DEPARTMENT USE ONLY J <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 DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> i <br /> FEE �� 1 <br /> LESS <br /> PRORATION { _ <br /> PLUS <br /> PENALTY y <br /> OTHER '101 <br /> 3 <br /> OTHER / <br /> Received by Date Receipt No. Permit No. J Issu nce 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 />