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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> :r. (For Non-Transferable, Revocable, and Suspendable) <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 /> rn Business Name (DBA) .fid."5. GGl, C9 C;;-Yew Address 12• E' <br /> aOwner. Address _ <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. f Emergency Telephone No. <br /> Contractor Licence No. 3's`93 <br /> L Applicants Name (Print) � p W Title -0. A16A .. 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) i <br /> Serial No. " CAL. License No. CAL. Liccnse Renewal No. " I <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 <br /> 3. ❑ 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. 0 SANITATION PERMIT <br /> Job Address/Location Z SIE �y71G it/ I <br /> Owner .5.0i ,0ZA Address E r t <br /> ❑ SEPTIC TANK ❑ CESSPOOL JI LEACHING FIELD JI SEEPAGE PIT ❑ PACKAGE PLANT M <br /> PERMANENT ❑ TEMPORARY ❑ NEW - REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 f t <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 I Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 j <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq" Ft. = <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 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, and rules and regulations San Joaquin Local Health District. <br /> 4 <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH EJ January 1 &Received By January 31 ❑ Jufy 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> -- BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION i <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER ;: <br /> I61 �� 3N /F <br /> Received by Date 13 Receipt No. Permit No. lbsuancetDale f Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES. 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON„CA 95201 <br />