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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENViRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatio hereby made to car r�o n business in thg,juriissdictional area of the San Joaquin L of Health District <br /> In Business Name D6AI V ARGIlics k5r<k sue_ � g� <br /> a Owner 1►91 C',�Kr�r/� Address /S to r7CA— AVe- <br /> Address <br /> j.Firm Partners, Addresses and Tel hone Numbers <br /> aBusiness Telephone No. <br /> Contractor Licence No.��Sf c/Sr Emergency Telephone No. - <br /> L Applicants Name (Print) Title <br /> o Date <br /> Please check Applicable Category ry(t-7)and FIII in the Required Information <br /> ry t• ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 00 <br /> I For Jul 1, ' June 30, 19 Disposal Sites <br /> I Description(Make/Yr., Color) <br /> Serial No. CAL. License No. <br /> CAL. Licc,se 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 j <br /> t <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name <br /> R.S. or R.C.E. Na. <br /> Test Location <br /> Test Date/Time <br /> 4. R SANITATION PERMITL/ <br /> Job Addre Location � 7 76 11�01.i r`NLA40 o„� <br /> Owner F& Address �"7° y� <br /> ❑ SEPTIC TANK 1:1 CESSPOOL ❑ LEACHING FIELD <br /> ❑ PERMANENT ❑ TEMPORARY 11 NEW � SEEPAGE PIT 1:1 PACKAGE PLANT <br /> ❑ REPAIR 13 OTHER � . <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site fi�17D sc'mp 70 �X"�S7`5,i9z �` <br /> No. of Units Equipment Storage/Cleaning Location(s). <br /> 6. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name W <br /> (slant Location here Certified <br /> Plant Capacity No. Units Served F <br /> . � <br /> 7. 1:1 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 /> 4 <br /> l <br /> 4 <br /> I hereby certify that I have prepared this application and hat the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a� and re at" of the Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> / a ^J 4 <br /> d <br /> i <br /> R DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑,EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE s REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE <br /> AMOUNT <br /> LESS <br /> PRORATION t <br /> PLUS V <br /> PENALTY ,* - <br /> OTHER <br /> t <br /> OTHER # <br /> i <br /> Received by 6 Date t too_. b-V0 <br /> Receipt No. Permit No. Issuance Date Mailed <br /> APPLICANT—RETURN ALL COPIES TO:- - ENVIRONMENTAL_HEALTH PERMIT/SERVICESDelivered- <br /> a _ i601 E.NAZELTON AVE.,P.O.Box 2009 -..STOCKTON,CA 85 4 <br />