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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> .W . .Jon-Transferable, Revocable, and Suspends <br /> ENVIRONMENTAL HEALTH PERMIT", SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on usiness in the jurisdictional area of the Saa-Jpaquin Local Health District <br /> 3usiness Name (DBA) �•z ?`cL <br /> %J7 Address f �• e�< /4' % /J1TG p <br /> Dwner 4 . 2 - t�z 41e, Address <br /> =irm Partners, Addresses and Telephone Numbers _ <br /> 3usiness Telephone No. <"5lf-� Emergency Telephone No. <br /> 3ontractor Licence No. -,—5 <br /> applicants Name (Print) A. ���I e,'_ <br /> R Title C Date <br /> 2lease check Applicable Category (1-7) and Fill in the Required Information _J <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. Licc ase Renewal No. <br /> apacity Gal.,Weights & Measures No. <br /> Equipment Parking Address I <br /> 2. ❑ PUMPER YARD <br /> -or July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Lp cation Test Date/Time <br /> 4. El SANITATION PERMIT <br /> Job Address/Location C <br /> Own � — � Address S � ✓h �� <br /> l� 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 1 <br /> Where Certified <br /> Operator Name <br /> Plant Location __ r7C <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 J <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 an e ions the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 4 L -b -. <br /> j Gh <br /> FOR DEPARTMENT USE ONLY <br /> FFee Is Due: ❑ ANNUALLY ® PER UNIT ❑ PER SITE ❑ EACH El January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> �S <br /> LESS <br /> PRORATION <br /> PLUS <br /> .PENALTY ` <br /> l� <br /> OTHER <br /> OTHER L� - <br /> 166C/ SS / <br /> Received by Date Receipt No. Permit No. Iss ante bate Marled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br />