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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 /> 4 <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 Health District <br /> 4t ,F Business Name (DBA) 5iu0-VdY,A Z- <br /> Address 44 P4A.1r6CA <br /> a Owner SGtf-GrG� Jf� Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. � 3� 7 Emergency Telephone No. <br /> Contractor Licence No, <br /> Applicants Name (Print) Title 6GN7'91&f; Date 15k�. 91, t Z <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 h <br /> 3. Pf 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. ❑ SANITATION PERMIT <br /> ' Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ 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 CLEANING, 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, an s a d reg ulatio S of a San J quin Local Health District. <br /> APPLICANT'S SIGNATURE X t <br />_ E i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY 0 PER UNIT I:1 PER SITE ❑ EACH" ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT 7 <br /> BASE EXPLANATION BILLING REMITTANCE - AMOUNT OUE CHECKED I <br /> DATE DATE REMITTED AMOUNT <br /> FEE . [ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> - OTHER i <br />' I <br /> OTHER <br /> Received by - Date Receipt No. Per i o. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKT N;CA 95201 <br />