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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE ` <br /> Applicatio 's hereby mad o carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) © O — AQ .E �.� •���'�FAddress fid, L.0 <br /> a Owner C Address <br /> I J Firm Partners, Addresses and Tele hone Numbers <br /> aBusiness Telephone No. 5� �� Emergency Telephone No. <br /> Contractor Licence No. 349 <br /> Applicants Name(Pririt), -�, 601& Title sT Date 9'f4" 79 <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, a ' June 30, 19 Disposal Sites _ a <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 r , <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored X 1 �Fr f k h k <br /> 3. ❑ PERCOLATION TEST 4 <br /> R.S. or R.C.E. Name • •R S. or R.CiE. No. A •t , �` <br /> Q + .. ; <br /> Test Location �_ _ Test Date/Time � 1 <br /> 4. WSANITATION PERMIT34 r7A7? <br /> Job Address/Location � M <br /> Owner GA8Zoi 4 is d Address 7.3 �_ •C�'—r6[ � / � �~:I <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE IT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR MOTHER Fjzr4p 13-iPD , <br /> 5, ❑ CHEMICAL TOILETS For July 1, -,tune 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. 11PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> +Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Unii_s�S''erved <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 fi <br /> SIZE: O'Less Than 1,000 Sq. Ft., 0 More Than 1,000 Sq-!Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 t r <br /> if <br /> 1tr41� t, ! 4 <br /> I hereby certifyFthat l have prepared this application and that the workiwill be done in accordance with San Joaquin County <br /> -ordinances,state laws les and r ,�egultions Of th San Joaquin Local Health District. <br /> --� � �. <br /> APPLICANT'S-SIGNATURE X <br /> t � i <br /> FOR DEPARTMENT,USE ONLY. <br /> a t <br /> Fee Is Due: ❑ AtINUALLV ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31-i ❑ July 1 &Received By July 31 <br /> } • i i REMIT <br /> { BASE EXPLANATION t BILLING V REMITTANCE $ AMOUNT DUE CHECKED <br /> f t � ^� " } A{, AMOUNT <br /> DATE DATE REMITTEDp tk 4 <br /> FEE Y g .# ti f <br /> r f <br /> LESS ! 1 h 4 ` ✓� <br /> PRORATION l 1 <br /> PLUS <br /> -PENALTY — —- <br /> r <br /> OTHERt `'t` <br /> OTHER f� <br /> J i.ti <br /> FM67 Q <br /> Received by Date Receipt No. a it o. Is uanc Date Mailed. ishvered <br /> APPLICANT—RETURN ALL COPIES TO:` ENVIRONMENTAL HEALTH PERMIT/SERVICES E.HAZELTON AVE.,P.O.Box 2089 STOCKTON, 05 <br /> N, i <br /> . '- - <br />