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APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> v ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is herebFv-rRade to carry on b 'Hess in the un Ictional area of th!e,,�r JO um Local H alth Dist ric�-L <br /> `Business Name (DBA) � � i;" 1 \ �".� :LX- Address ti is 9S' f {� "`sf [� <br /> z Owner Address <br /> u Firm Partners, Addresses and Tqephone Numbers <br /> _ � � <br /> Business Telephone No. `+r+ vp ' # a: „f Emergency Telephone No. <br /> ?Contractor Licence No. t — a. <br /> Applicants Name (Print) - I 1 Title L,:' '�' 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 /> N <br /> Description(Make/Yr., Color) <br /> a <br /> `Serial No. CAL. License No. CAL. License Renewal No. 4 <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 <br /> r3. ❑ 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 PERMIT <br /> `Job Address/ ocation .)t.. <br /> Ownerj; Ad1) IP,+,�� - Address <br /> 11Imo <br /> - <br /> ❑ SEPTIC TANK CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> r5ePERMANENT ❑ TEMPORARY ❑ NEW WREPAIR ❑ OTHER <br /> 5. ❑ 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 ' <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. Pt. <br /> L❑ DRY CLEANING, Chemicals Used/AmounVMo. - Q <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 rule�! San Joaquin Local Health District. _ <br /> I.. APPLICANT'S SIGNATURE X <br /> TJX <br /> ` FOR DEPARTMENT USE ONLY -t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 11 PER SITE ❑ EACH ❑ January 1 8 Received By January 31 [1 July 1 8 Recewv ,iiy July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION AMOUNT DUE CHECKED <br /> LDATE.__ _ DATE ._. , . REMITTED _ . _. . _ _ AMOUNT <br /> FEE f�s <br /> LESS <br /> PRORATION <br /> Isis PLUS <br /> PENALTY <br /> OTHER <br /> 6. OTHER <br /> — <br /> Recanted by I Date Pen,nit No. 1A.Ugnte Date ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />