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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 /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE `A <br /> Applicati n s hereby ade to car on tipsiness int jurisdictional area of the San Joaquinpt�oval Health District <br /> y Business N�e (DBA) �1­6f�'�'s � Lt`f� Address <br /> z Owner. Coi e Address s'�? <br /> nO Firm Partners, Addresses and Telephone Numbers � <br /> M Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) '771✓h 1Z . P-Ca )t - Title Date /3- 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, June 30, 19 Disposal Sites �1 <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 _N, l%, <br /> 2. ❑ PUMPER YARD LA <br /> For July 1, June 30, 19 Ilk <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. ❑ SANITATION PER <br /> Job Address/Location V I <br /> Owner Mhlu Foalvuy Address ► e <br /> ❑ SEPTIC TANK ❑ CESSPO L LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ® REPAIR ❑ OTHER I <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) I <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 41;�` <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> 1 f <br /> DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and th t the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and and regulations he Sari aquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTME ONLY Lam' <br /> Fee Is Due: El ANNUALLY El PFR UNIT ❑ PER SITE 11EA H 1eS❑ January 1 &Received By January 31 ❑ July I &Received By July 31 <br /> REMIT <br /> BILLING" REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATEDATE REMITTED <br /> t AMOUNT/ J <br /> FEE <br /> LESS <br /> PRORATION ,x <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> C7 1-7 to <br /> 'I <br /> Received y Date Receipt No Permit No. ssuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,C <br />