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Applications WIII Be Processed When Submitted Properly Completed. Be SureTo Sign TheApplication. <br /> APPLICATION / <br /> (Far Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL 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 Distr t <br /> H Business Name (DBA) 11p, B�Y� '0/Y ¢ oe ey Address 050-�aoX <br /> aOwner �+ p ___'dam Address <br /> 70 <br /> Firm Partners, Addresses and Telephone Numbers - <br /> aBusiness Telephone No. _sr-�z-3r - yam' Emergency Telephone No. <br /> Contractor Licence No. <br /> L4ApplicantsName (Print) __ - Title _ Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information 6� <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. 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. W SANITATION PERMIT <br /> Job Address/ Otis <br /> Owner Lo � b y 1nf f/1GQ <br /> Address.�ODO J�eLd Q.P17 �� �.CLCGI t,,t <br /> SEPTIC TANK ❑ CESS OCIL all LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ®' OTHER f%"L 7-L- <br /> 5. <br /> e5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 —[ <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> S. ❑ 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 rul and regulation 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 18 Received By January 31 ❑ July 1 &Received By JWy 31 <br /> REMIT <br /> BASE. EXPLANATION BILLING REMITTANCE $ AMOUNT OUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> dr — <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER 0 <br /> OTHER <br /> 135 S �� <br /> Received by date Receipt Na. Permit No, Issuance Date ai Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1001 E.HAZELTON AVE.,P. "1T •2009 STaCKTON,CA 9SM1 <br />