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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application.J <br /> - APPLICATION , <br /> v ,,� <br /> (For Non-Transferable, Revocable, and Suspendable) - r <br /> ENVIRONMENTAL HEALTH PERMIT SEP TAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San <br /> Z7 <br /> Joaquin Local Health District <br /> Business Name {DBA) [� B �Ci!� ,S'�"LlIe ' Address—/ ' 5' �. <br /> a Owner t —Lo Address /74-5- S, Lj� /� <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. (eb 0'�6 i Emergency Telephone No. <br /> a Contractor Licence No. <br /> I L Applicants Name (Print.) iL. // WR,,i Title <br /> .. Please check,Applicable Category(1-7)and Fill in the Required Information Date <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) � + <br /> E Serial No. �. CAL. License No. w CAL. License Renewal No. <br /> Capacity Gal., W_ei hts & Measures No. I <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD "' 'r N <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 f <br /> Test Date/Time � <br /> 4. X SANITATION PER I ! w <br /> r Job Addr /Location, <br /> Owner F L .Address © �f U <br /> SEPTIC TANK ❑ CESSPOOL ` LEACHING FIELD r SrSEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT EMPORARY L�NEW r`- ❑ REPAIR 13 OTHER <br /> 5" ❑ CHEMICAL T (LETS For July 1,',-June 30, 19 ' <br /> Type Construction Dls o J . Site <br /> .. P r . <br /> No. of Units I Equipment Storage/Clean!rg Location(s) 1 <br /> 6. ❑ PACKAGE TREATMENTtPLANT For July 1, -June 30,19 j <br /> Operator Name +- ! "i I <br /> Where Certified <br /> Plant Location <br /> Plant Capacity � ." "`�.. "� "'"No.Uni`*„rS; <br /> — <br /> No. Units ed j ) <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 x <br /> SIZE: ❑ Less Than 1,000 Sq. Ft ❑ More Than 1,000 Sq. Ft. i t <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 accord ince with San Joaquin County <br /> ordinances, state la , an ules and regul , nsI0R' he San Joaquin'Local Health District. € <br /> APPLICANT'S SIGNATURE X , <br /> �� �C. <br /> _ r <br /> F <br /> ) <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUA ❑ PER UNIT ❑ PER SITE EACH <br /> LLY ❑ January-1 &Received By January 31 ❑ July 1 &Received By July 31 i <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> ' t <br /> FEE AMOUNT <br /> � <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ♦Q �w�q <br /> OTHER <br /> OTHER I " <br /> Received by Date <br /> ' t - Receipt No. Permit No-.. r I uance ate Mailed Delivere <br /> - 'APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ' - 1601 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA 95201 <br />