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Applications Will Be Processed When Submitted Property Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendabie) SEPTAG-E <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE - <br /> Application is hereby made to cry on,business in the jurisdictional area of the San Joaquin Local Health District <br /> t�l. . ,Fri VJ"J Y IOW i r+ Address <br /> -AWE i:ri�.7� .. .I I �C� <br /> w Business Name (DBA +„<Owner L—fT rl •l r-.7-7C+ s ;Address Z (TI` <br /> g Firm Partners, Addresses and Telephone Numbers Gig-ri <br /> iBusiness Telephone No. 2 fjE'�'I �• Emergency Telephone No. <br /> 11 Contractor Licence No. - C <br /> Applicants Name (Print) - Title rl Date <br /> Please cheek 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. o Chemical Toilets Stored <br /> 3. PERCOLATION TEST p <br /> R.S.or R.C.E. Name ?• R.S.or R.C.E. No. t 6 3 g <br /> Test Location NLA(I 'p1 aut LL2 `[1931 E pQp kE.rCl Test nate/Timee} - <br /> 4. ❑ SANITATION PER —t <br /> MITJ Ob 21ci 7 ` s ©--z I <br /> Job Address/Location - - -- - <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ 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. 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 rules and regulations of the San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July I S Received By Jury 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ►� /o' g-89 /23/ <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAIELTON AVE.,P.O.Boa 2009 STOCKTON.CA W201 7 <br />