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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. S <br /> APPLICATION ; <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> SEPTAQE :J <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application 's hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health Dist ict <br /> rn Business Name (D A) z' Address °` <br /> z Owner Address � - <br /> 4 <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 36 �/ Emergency Telephone No. <br /> Contractor Licence No. -747 <br /> fid' <br /> LApplicants Name (Print) +p `�z��- Title &-- Date --z v <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. 0-PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. 9 CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. j <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD 6F <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored N .; <br /> No. of Chemical Toilets Stored t N <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name '~"'�°"~�y -?`Ii 1`# R.S. or R.C.E. No. { N <br /> Test Lkation Test Date/Time_ A <br /> 4. u SANITATION PERMIT ` <br /> 2'Sc�Z �2 <br /> Job Address/Location: Aid <br /> O ner Address �_ <br /> EPTIC TANK ❑ CESSPOOL Eft EACHING FIELD SEEPAGE PIT "❑ PACKAGE PLANT. <br /> I-7 PERMANENT ❑ TEMPORARY ;NEW 11 REPAIR.,.+ .❑(OTHCR <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, <br /> Type Construction s° Disp al Si�e '! -t,► I <br /> No. of Units I Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19� , <br /> Operator Name e----_�+= I Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served ! <br /> 7. ❑ 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 /> .I <br /> I 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 rul s and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> ogle- <br /> FOR DEPARTMENT USE ONLY ' <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNTDUE CHECKED <br /> AMOUNT � <br /> FEE 41 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER J�J <br /> 1 <br /> OTHER i <br /> 79 'Lim I /2.'6LOf� <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICESy� //-,o Lt/1601 E.Hj MELTON AVE.,P.O.Box 200�9y $TOCKTON,C <br /> Lf "Iz,�� 1"1 _,//--) 7 -- 00/ fi0.0/�37iYi�/ I <br />