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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Appllcatlo?i 'r' <br /> APPLICATION, <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> I Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District, <br /> y Business Name (DBA) 4,L, !,: %./ i-- Address i <br /> ( a Owner <r � - Address <br /> ( Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> -i Contractor Licence No. <br /> Applicants Name (Print} < �� � +�� Title P'a'res Date <br /> �j �`=�- <br /> ' <br /> Please check Applicable Category (1-7)and Fill in the Required Information J <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 i <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> I <br /> No. of Vehicles Stored _ •- <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST ; y <br /> R.S. or R.C.E. Name <br /> R.S. <br /> .S. or R.C.E. No. <br />! Test Location Test DatelTime <br /> 4. ❑ SANITATION PERMIT _ g <br /> Job Address/Location �� �G/ f t'Zs�l N �• c > <br /> Owner `� Y Address <br /> 0-'S'EPTIC TANK ❑ CESSPOOL +'LEACHING FIELD ❑ SEEPAGE PIT' ❑ PACKAGE PLANT t <br /> ❑ PERMANENT ❑ TEMPORARY '❑-NEW— , 13 REPAIR 13OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 -J.- <br /> Type <br /> J_Type Construction Disposal Site k <br /> No. of Units Equipment StoragelCleaning Location(s) <br /> 6.- ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name _ Where Certified -i4 <br /> Plant Location <br /> Plant Capacity t No.Y Units'Served <br /> 7. ❑ LAUNDRY%-For July 1, -June 30, 19 <br /> SIZE70' Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. f <br /> ❑ DRY CLEANING_, Chemicals Used/Amount/Mo. . <br /> r s.-- <br /> I hereby certify that I have prepared this application and-ffSat the work wi1P'be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and reg iations_of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ;� <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due. ❑ ANNUALLY' ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ JWy 1 &Received By July 31 <br /> RASE ',,, '+ REMIT EXPLANATION BILLING REMITTANCE $ <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> � <br /> AMOUNT <br /> FEES» <br /> f CESS—� - •� - r��.�,,.,��_--tea: .�. �,,, _ - <br /> PRORATION - <br /> PENALTY <br /> 4 1 <br /> OTHER i <br /> OTHER <br /> F Received byDate Receipt No. Permit No. Issuance Date M ed Delivered <br /> i' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201 - <br />