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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) $EPTAGE <br /> ENVIRONMENTAL-HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business ip the jurisdictional area of the San Joaquin Local Health District <br /> ,F Business Name (DBA) SC20S ,Z11,�.. ...Address 70°ROk 14S'0 <br /> aOwner _ Address <br /> 3 Firm Partners, Addresses and Telephone Numbers <br /> 1LBusiness Telephone No. _ ��'��� Emergency Telephone NO. ` <br /> Contractor Licence No. Z <br /> Applicants Name (Print) �� L3=� �.. S1M� .. _ _ . .,. .,Title � rJ' A—rCQ2 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= - = DisposalLSites ;L <br /> Description(Make/Yr., Color) <br /> Serial No. - CAL. License No. CAL- License Renewal No. <br /> t <br /> Capacity Gal., Weights & Measures No. -- - <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 .k_y +, 9 p <br /> No. of Vehicles Stored ` <br /> No. of Chemical Toilets Stored <br /> !3. ❑ PERCOLATION TEST € a <br /> R.S.or R.C.E. Name R.S.or R.0.E. NO. r.9, t`% <br /> Nest Lobation_ Test Date/Time < <br /> j4. SANITATION PERMIT 5t' ,�s� � iMj�.«. w. ..-- �._Fm � � �. i ��. �' ii,_S,r' <br /> /LocatintJJob Addrez9 ! <br /> IOwner Address <br /> 1❑ SEPTIC TANK '--13 CESSPOOLS LEACHING FIELD I B SEEPAGE PIT ❑ PACKAGE PLANT <br /> fBPERMANENT ❑ TEMPORARY ❑ NEW I REPAIR ❑ OTHER. <br /> 5. El CHEMICAL TOILETS For July1,-June 30, 19 1 t II <br /> Type Construction - R'� �"N Disposal Site # 4 <br /> r No. of Units -_ '1'F'Eq6i,pment Storage/Cleaning Location(s) t <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 , <br /> Operator Name — 1----- __. Where Certified .. - <br /> ( Plant Location <br /> f Plant Capacity No. Units Served r <br /> 7. El LAUNDRY Tor Jul 1� -'June 30, 19 +) <br /> SIZE: ❑ Less Than`1,000 Sq. Ft., MorelThan 1,000 Sq. Ft. ¢ <br /> ❑ DRY CLEANING, ChemicalS,Used/Amouht/Mok <br /> ` � �.� f °•l ' . <br /> t I he'r2by certify that I`have prepared.this applicflon nd that the work will be done in accordance with San Joaquin County <br /> ordinances;st8t1@�laws,a rakes and:r ations of Sari Jo irk=9fal Health District. <br /> y4. 0, _ i <br /> APPLICANT'S SIGNATURE X <br /> - f i. FOR DEPARTMENT USE ONLY ,. . <br /> 4 <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑:EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> - BILLING - REMITTANCE $ A <br /> REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> GATE t DATEsREMI77ED AMOUNT <br /> 44 <br /> LESS 1- <br /> PRORATION } '" <br /> PLUS• <br /> PENALTY <br /> OTHER �A <br /> OTHER <br /> Recti �%=Ta""Dat `' Receipt No. Permit No.',; ' "-' su eD te--Mailed^^ —Delivered <br /> APP LI NT—RETURN ALL COPIES TOc ENVIRONMENTAL HEALTH PERMITI$ERVICES'— 1601 E.HAZ AYE.,P.O.Boa 2lhr"STOCKTON,CA 95201 <br />