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APPLICATION <br /> 'For Non-Transferable, Revocable. and Suspendablot <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Appl icati9n is hereby ma a tp_c r on busin in the ri dictional area of the S Joaquin Local Health District <br /> yBusiness Name (DBA) L- �. Address C L� � <br /> cOwner L C !�_ ` Address '- — <br /> aFirm Partners, Addresses ape) I hone.Numb rs <br /> a Business Telephone No. ��jj - Emergency Telephone No. <br /> Contractor Licence No. <br /> a <br /> L Applicants Name (Print) r f [ Title <br /> ate <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) L <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. 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 Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Addres /Location > 3'> e_-, 1 t� <br /> Owner ` l ALJ ]V 1 6 k r-�� ti' v` \-7_ Address <br /> 191�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 hav prepared this application and at the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a d r_ es an re ulati`ns th S oa n Local Health District. <br /> APPLICANT'S SIGNATURE --' -- - - <br /> '1 <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE. $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE ATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS I I <br /> PENALTY <br /> OTHER 1✓ 41 t ae !l_� <br /> OTHER UJ sn <br /> Received by Date Receipt No. Permit No. Issuance Date _ ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />