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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 y <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name (OBA)r� 44 Sot\" �3_A' �Address R <br /> 4 Owner Address <br /> j Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. _. _ Emergency Telephone No. _ k <br /> Contractor Licence No. <br /> L Applicants Name (Print) ��1,4 L" 1&4 S Title F—ST 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 G1 <br /> Description(Make/Yr., Color) <br /> Serial No: I CAL. License No. CAL. License Renewal No. <br /> Capacity _ Gal., Weights & Measures No. ) <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD k 3 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored f <br /> 3. ❑ PERCOLATION TEST F <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. 2 SANITATION PERMIT <br /> Job Address/Location 1 1 S U 14 <br /> Owner Address �:7nw� S 'rpt r y` 1- , h-fA7X D'5,044 <br /> SEPTIC TANK El CESSPOOL <br /> FIELD ' EEPAGE PIT El <br /> PLANT <br /> BPERMANENT ❑ TEMPORARY ❑ NEW 2 REPAIR OTHER � fS <br /> U <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 /> t <br /> Operator Name l ' Where Certified (("1 <br /> t <br /> Plant Location <br /> Plant Capacity No. Units Served r <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 /> - a <br /> i <br /> I hereby,cortify that I have preparedthisapplication and that the work will be done in accordance with San Joaquin County <br /> t <br /> ordinances, state laws, aj4 rules and reg ations of tft San um ocal Health District. <br /> APPLICANT'S SIGNATURE X 1# <br /> it <br /> FOR DEPARTMENT USE ONLY 1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE w, 'AMOUNT DUE REMIT <br /> CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE u 6 0 <br /> LESS ` <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 1. <br /> { OTHER ii EE <br /> Received by - - - Date Receipt No - _Permit No. KlanCeDaX —Mailed. Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH,PERMIT/SERVICES ,1601 E:HAZELTON .,P.O.Box 2009 STOCKTON,-CA 9520 <br />