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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. \ <br /> APPLICATION \\\ <br /> f_ (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> 1-7060` LIQUID WASTE �`FJ�- Oda 0r-3D <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name (DBA)"-/'4LA2_ &'1,Sr44 F, SdRSG- Address es � �T j 4sZa <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. �ln�—9,560 7 Emergency Telephone No. <br /> C <br /> 4 <br /> Contractor Licence No. <br /> Applicants Name (Print} �T.Q1dC�E J Title S�TIA4,4Td/e - Date / --LID^80 <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. License Renewal No. <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. B SANITATION PERMIT <br /> Job Address/Location ZL��A') my >�Q� <br /> Owner j':;.�eA'tiJzeA Wy J8A_11 Address •� X �97 Il�b <br /> ❑�S,EPTIC TANK 1:1 CESSPOOL ❑ LEACHING FIELD 2-SEEPAGE PIT 11 PACKAGE PLANT <br /> p _-� <br /> "' PERMANENT ❑ TEMPORARY ❑ NEW 9—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. <br /> ❑ DRY CLE=ANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I ha a prepared this application and t at the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, d ules and gulatio the S Joacjuin Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY J <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 Q Juiy 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE . EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> �✓O AMOUNT <br /> FEEtAe <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Iss eD e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2 AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br /> i <br />