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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign.The Application. v <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) " <br /> ENVIRONMENTAL HEALTH PERMIT r SEPTAGE <br /> L�I LIQUID WASTE r <br /> Application is hereby made to carry on business in the jurisdictional area of the Joaq 6 Local Health District e--� <br /> ... <br /> F Business Name (DBA /C:r Address— <br /> 4 <br /> E <br /> a Owner i�l _.� !u L L z� fZ Address <br /> :i-Firm Partners, Addresses and Telephone Numbers <br /> IL <br /> Business Telephone No. 6 �l Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print, F,:!Z, it 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 S <br /> Description(Make/Yr., Color) <br /> Serial No,i CAL. License No. CAL. Liccnse Renewal No. C'1J <br /> Capacity Gal., Weights & Measures No. -�-- <br /> Equipment Parking Address <br /> 2. 11 PUMPER YARD i <br /> p <br /> For July 1 June 30,19 . <br /> No. of Vehicles Stored f <br /> No. of Chemical Toilets, tored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name. .3 R.S. or R.C.E. No. + 3 <br /> Test Lavation Test Date/Time <br /> 4. ❑ SAN ITATION�PERMIT <br /> Job Address/Locati- r f �✓1✓l F °�l 1 <br /> Owner ^ !! ,A7ddre9'S — 7,q 57— <br /> (Z <br /> 9?-SEPTIC TANK'�r� CESSPOOL _ UFFIELD E] SEEPAGE PIT t`0 PACKAGE PLANT <br /> .�.� . <br /> ❑ PERMANENT " ❑ TEMPORARY ❑ NEW CD REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL:TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site �—►-= jnr <br /> No. of Units Equipment Storage/Cleaning Location(s) i <br /> 6. 0 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name rY:e.._ Where Certified <br /> Plant Location'' _4 <br /> Plant Capacity ' Y, �a -:,N&-Units Served ? <br /> 7? 11 LAUNDRY For July 1, -June 30, 19 .� } <br /> SIZE: gess Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. . <br /> DRY CLEANING, Chemicals Used/Amount/Mo. <br /> ft <br /> Xhereby 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 rul/esand re `lation of the <br /> �San Joaqun Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY p <br /> Fee Is Due: ❑ .ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH © January 1 &Received By January 31 ❑ July 1 &Received By July.31- 3 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED r <br /> ! { DATE DATE REMITTED AMOUNT 4 <br /> FEE <br /> LESS ! <br /> - PRORATION _ }, <br /> PLUS Z <br /> PENALTY' Alli ir ' <br /> OTHER <br /> OTHER <br /> a 3a a� ; <br /> Received by Date Receipt No Permit No. IssLIance De I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601E.HAZELTON AVE.,P.Q.Box 2009 STOCKTON,CA 95201. ,?� <br />