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_ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, "� .•w <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> ApplicatiDgis bbus <br /> er��ppy made to carry on Vi=n the jurisdictional area of the San Joaquin Local Health District L 8� <br /> Business Name(DBA) N. <br /> y �'. S.4/"/,&dC1 ,F �y Address_L�d Cao I' / 8 T 7Tir✓?-o c/ �'�/ <br /> c Owner 011 /194 Address <br /> Firm Partners, Addresses and Telephone Numbers —' <br /> Business Telephone No. Emergency Telephone No. <br /> :1 Contractor Licence No. //6d,3O <br /> L Applicants Name (Print) y C. 6,4,,V 4,4 CrAlZ TitleOWE/F_ i 9 .a7 9 <br /> Please check Applicable Category(1.7)and Fill in the Required Information �o r: v OQ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites 1 <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL.License No. <br /> CAL. Lick-se 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 <br /> R.S. or R.C.E.Name R.S.or R.C.E.No. <br /> TestLocationTest Date/Time <br /> 4. A SANITATION PERMIT <br /> Job Address/Lo _ //= z1� <br /> Owner-.G7 7 W r'/14:5,P Address &ei <br /> M 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 /> Isype Construction Disposal Site 1 <br /> o.of Units Equipment Storage/Cleaning Locations) �j <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, k>, <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. ce�� <br /> I hereby certify that I have prepared this application and t the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,§D�f'rul akl/�Jr�egulationnss of the J quin Local Health District, <br /> APPLICANT'S SIGNATUREX 24 ^��-�' <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: 13 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Receivetl By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS T J <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER D <br /> OTHER <br /> d �3 b rm 3 11 !o <br /> Receivetl by ate Receipt No. Permit No, Issuance Date iletl Deiiveretl <br /> APPLICANT—RETURN ALL COPIES To.. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AV .8"2000, STOCKTON,CA 651st <br />