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APPLICATION <br /> (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 Joaqty in Local Health District <br /> rn Business Name (DBA) G, %vT�iv�y�- 1` f�"Y Address X d' /SoX //0 <br /> i Owner Lce Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> `a Business Telephone No. S 3 �'/ 7 Emergency Telephone No. �h <br /> ` / 6G – 38d <br /> Contractor licence No. - _.-- <br /> �Applicants Name (Print) ee' ��wf�i0�✓z —Title --. 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) — <br /> Serial No. CAL. License No. CAL, License 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 <br /> No. of Chemical Toilets Stored pp <br /> 3. ❑ PERCOLATION TEST M <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test-Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner /3�s'e7-7".° iil'7er/ter/sc+'s Address <br /> 0 SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ® NEW ❑ REPAIR ® OTHER : L!'v / <br /> 5. 11 CHEMICAL TOILETS For July 1,-June 30, 19 <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 W <br /> Operator Name 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 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 r les and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> GAIc_ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY, Ir PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 a Received By July 31 <br /> BILLING RE IREMIT <br /> TTANCE $ <br /> BASE ,EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> ' I AMOUNT <br /> 4 c <br /> FEE V 0 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER I <br /> OTHER <br /> Receiyeo.ey Date I Issuance Dat Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Boa 200 STOCKTON,CA 95201 <br />