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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. Y <br /> r APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is h rjurisdictional made to carry on bu ess in the area of the S foaQuin�Local Health District <br /> rBusiness Name (DBA) —tom G(7 r /./C <br /> a Owner Address j -� y <br /> Address <br /> 1 Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. _� Emergency.Telephone No. <br /> Contractor Licence No. ? <br /> L Applicants Name (Print) 4 AeTitle <br /> Please check Applicable Category ) Date " <br /> { g ry (1-7 and Fill in the Required Information <br /> 1• ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July I. - June 30, 19 Disposal Sites � <br /> Description(Make/Yr., Color) <br /> Serial No. I CAL. License No. <br /> Capacity CAL. License Renewal No. <br /> -- - - �.-�_...� a,Gal:_,Weights-&-Measures No. <br /> Equipment Parking Address - '3- -N <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19f <br /> No. of Vehicles Stored - <br /> .No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST , <br /> R.S. or R.C.E. Name _ `_2R:S. or R.C.E. No. <br /> Test Location %­_ �li 4 <br /> Test Date/Time <br /> 4. ❑ SANITATION PERMIT , :; p <br /> Job Address/Location <br /> Own _ <br /> SEPTIC TANKF x❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT• �:❑rP,ACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR t- 'El OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 { _mss'; .0 <br /> t <br /> Type Construction Disposal Site <br /> No. of Units .tk-"% _1` Equipment Storage/Cleaning Locations) ` <br /> 6. ❑ PACKAGE TREATMENT PLANT` f rliuly i, -June 30, 19 ± ,- <br /> Operator Name i' t: <br /> Where Certified <br /> Plant Location 3 = a <br /> � 1 <br /> Plant Capacity ' ,No. Units Served I <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 �a <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑,More Than 1,000_Sq.%Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. v i <br /> t <br /> I hereby certify that I have prepared this,application and that thea work willlbe done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and re Olatlions f the a Joaquin Local Health District. <br /> APPLICANT'S SIGNA7URE.X <br /> y` <br /> .FOR DEPARTMENT USE.ONLY t <br /> [FIE,ee;IS Due: Q3 ANNUALLY ❑ PER UNIT s <br /> ` PER SITE EACH ❑ January 1 R Received By January 31 ❑:July_.} &Received By July 31 <br /> i <br /> I BASE EXPLANATION��• BILLING REMITTANCE $ a REMIT _ <br /> •a DATE DATE i REMITTED AMOUNT DUE CHECKED <br /> AMOUNT + <br /> " <br /> LESS <br /> PRORATION <br /> PLUSPENALTY A <br /> OTHER <br /> OTHER <br /> r <br /> Received by Date l Rece pt Na Permit No,' <br /> Issuarsce ate Mailed Delivered ./ <br /> APPLICANT--REYLFRN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009. STOCKTON,CA 95201 .nF3P! <br />