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APPLICATION r <br /> Non-Transferable, Revocable,and Suspend <br /> '--tNVIRONMENTAL HEALTH PERMIt '-' SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) E_A'�' �aiYr rt SviY Address o0 /Sof //a /IYfd���Td <br /> zOwner � �P A�✓��an-Y Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> n.a Business Telephone No. S z 3 Emergency Telephone No. <br /> Contractor Licence No. S'�G <br /> L Applicants Name (Print) Title - Date <br /> Please check Applicable Category(1-7)and Fill In the Required Information UJ <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. Liccnse 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 - <br /> 3. ❑ PERCOLATION TEST 9.+ <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 y S.y�l�' /><s .�i►liu✓P <br /> Owner �3 o.1 eTr,' f i, e)-�Jr/sN'S Address <br /> ® SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY RINEW ❑ REPAIR OTHER F•'Lyp r /3ra <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 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 /> 1 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 /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING RE ITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> [FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER -- <br /> � <br /> Issuance DaMailed Delivered <br /> Receiv y Date Receipt o. Permit No. t <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 7601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />