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Applications Will Be Processed'When Submitted Properly Completed:Be Sure-To Sign'The Application. f�` j <br /> APPLICATION . <br /> (For Non-Transferable, Revocable,and Suspendable) f <br /> t r ,_ <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 r.Health District { <br /> ,r'Business Name (DBA) , JQ G .- Address tom.a- SM4-4-) <br /> aOwner .... Address - - <br /> J Firm Partners, Addresses and Telephone Numbers <br /> IL a Business Telephone No. <br /> P .,Emergency Telephone No. <br /> Contractor Licence No. - <br /> L Applicants Name (Print) J ._—Titlei <br /> La�' Date <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 f Gal", Weights &Measures No. <br /> Equipment Parking Address T t <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 # F <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Sto?6d <br /> 3. ❑ PERCOLATION TEST <br /> 1 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No- <br /> Test Location r Test Date/Time " <br /> 4. M-1ANITATION PERMIT f <br /> Job Address/Location iio L4z) <br /> LJ <br /> Owner � <br /> A .. <br /> SEPTIC TANK 13CESSPOOL {BLEACHING FIELD B"SEEPAGE PIT`' ❑ PACKAGE PLANT <br /> 9.15ERMANENT IJTEMPORARY BREW ❑ REPAIR f 10 OTHER <br /> 5. DHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) t <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified t <br /> Plant Location <br /> Plant Capacity No. Units'Served `" > w 1 <br /> 7.¢.❑-LAUNDRY For July 1, -June 30, 19 t <br /> SIZE: 0;Less Than 1,000 Sq. Ft., 13More Than 1,000 Sq. Ft. - 'r <br /> ❑ DRY CLEANING, Chemicals Used/Amount-/Mo. <br /> ,I hereby certify that I ha a prepared this application and that the work will be done in accordance with San Joaquin County <br /> Ordinances, state laws, rules and reg tions of t, an Jo n Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 1 <br /> FOR DEPARTMENTr.US 'ONLY R <br /> t <br /> Is <br /> Fee Is Due: ❑.ANNUA_Lt_Y 13 PER UNIT ❑ PER SITE ❑ EACH*. +.❑January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> •s r -, "' + REMIT <br /> BASE , EXPLANATION BILLING REMITTANCE __7$ <br /> DATE NATE' ,� REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION .. `r: l fH�,?� l •'� CJ/I /GQ' .' - - + <br /> PLUS 1 <br /> PENALTY ."'1e- '7' /Urc�I /+ ' y .• -�� <br /> OTHER . <br /> OTRER <br /> �- <br /> Received by Date Receipt No. Permit No.. Issuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ,ENVIRONMENTAL HEALTH PERMITysERVICES - Y 1601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95201 <br />