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., � . . <br /> Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. �APPLICATION <br /> 2i, 4 _ (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 Heath District <br /> rn Business Name (DBA) � — �_dress <br />�€ Ownertal Address <br /> 7 Firm Partners, Addresses ,I,nj I leph ne Numbers <br /> ,. <br /> IL <br /> Business Telephone No. ; <br /> Emergency Telephone No. 7 <br /> Contractor Licence No. - r <br /> 1L Applicants Name (Print) " I 4. - ' ' yDat �-02� J <br /> e — <br /> Please check Applicable Category (1-7)and,Fill_in t e 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 l <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 /> TeL ation Test Date/Time �� 4 <br /> 4. SANITATION PERMIT <br /> Job Address/Location / ` �{ �' <br /> Ow eir r' Address <br /> SEPTIC TANK ❑ CESSPOO LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT a <br /> © PERMANENT ❑ TEMPORARY NEW 1.3REPAIR OTHER I <br /> 5. ❑ CHEMICAL.TOILETS For Juiy 1, -June 30, 19S`- <br />• Type Construction, I Disposal Site r, 1a-a0 <br /> No. of Units Equipment Storage/Cleaning Location(s) Qv <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 a l <br /> Operator Name <br /> Plant LocatioWhere Certified `+ <br /> n ' <br /> Plant Capacity L 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. —b <br /> ❑ DRY CLE=ANING, Chemicals Used/Amount/Mo" <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 rules and regulations of he San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 7 <br /> ,F <br /> FOR DEPARTMENT USE ONLY r <br /> vFee IS Due: ❑ ANNUALLY ❑-PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 July 1 &Recei d Ju y <br /> BASE EXPLANATION n BILLING REMITTANCE $ E IT •� <br /> DATE - DATE REMITTED _ AMOU T DUE H KED <br /> OUNT <br /> FEE <br /> LESS <br /> PRORATION r <br /> ' � r <br /> PLUS <br /> PENALTY <br /> OTHER <br /> -� OTHER <br /> i <br /> 24 <br /> Received b Date Receipt No. Permit No. Issuance Date Mailed Delivered. <br /> APPLICANT—RETURN ALL COPIES To: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE":,-P.O.-Box 2009 STOCKTON,CA 95201- <br /> f <br />