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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 SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> NBusiness Name (DBA) 45. 4,417_f�poY It Address Address P- d, 99OX -1(2a e sTa <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. S�3- y��� Emergency Telephone No. <br /> Contractor Licence No. /6 G-,5-'�?6 <br /> Applicants Name (Print) Title Date �-/y8�7' i "! <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. Licv se Renewal No. - <br /> i <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. ❑ SANITATION PERMIT f� <br /> Job Address/Location 'd:& l�-{A <br /> Owner 0PA11/01 k4S PN G r'79 e;7 ddress <br /> X SEPTIC TANK ❑ CESSPOOL J4 LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> Ii PERMANENT ❑ TEMPORARY 0 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. i <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r <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 rul s and regulat'ons of the San Joaquin Local Health District. . <br /> APPLICANT'S SIGNATURE X �� <br /> I I <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH -❑ January 1 &Received By January 31 ❑ July 1 &Received 8y July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REWTTED AMOUNT <br /> FEE L Ci's CJ <br /> k - <br /> LESS <br /> PRORATION <br /> f PLUS- 1 , <br /> PENALTY A ` <br /> OTHER '} <br /> } <br /> OTHER <br /> l ReCeived by Date Receipt No. Permit No. Issuan a Date Mailed - Delivered Ir <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 - -STOCKTON,CA 95201 ! <br />