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Applications Will Be Processed When Submitted Properly Completed:Be Sure To Sign The�Application. <br /> APPLICATION <br /> r (For Non-Transferable,Revocable,end 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 District <br /> Business Name(DBA) Address . moi` /Y. <br /> aOwner Address <br /> �o+ Firm Partners,Addresses and Telephone Numbers � <br /> a Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No.LZ <br /> � .� :�,• �� ; <br /> L Applicants Name(Print) z� 7 a /i�_/���t v r �. .� �...r- �I, <br /> Title Oate <br /> Please check Applicable Category(1-7)and Fill in the•Requlred Information <br /> } <br /> I. ❑ 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. _CAL. License Renewal No. <br /> Capacity, Gal.,Weights&Measures No. <br /> f Equipment Parking Address <br /> 2. ❑ PUMPER YARD , <br /> For July 1, June 30, 19 ` �0;i <br /> No.of Vehicles Stored f ° <br /> .No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST 3 <br /> A.S.or R.C.E. Name t' R.S.or A.C.E.No. <br /> Test Location ' Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address ,$ <br /> 1 ❑-SEPTIC TAN< CESSPOOL m LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> I ❑ PERMANENT ❑ TEMPORARY ❑ NEW ® REPAIR ❑ OTHER �I <br /> 5. ❑ CHEMICAL TOILETS 1For July 1,-June 30, 19,, C <br /> Type Construction tl r r Disposal Site*% ► 00 <br /> ` No. of Units Ps Equipment Storage/Cleaning Location(s) '— <br /> F 6. ❑ PACKAGE TREATMENT PP ANT For July 1,-June 30, 19 <br /> Operator Name I ? Where Certified <br /> Plant Location <br /> is <br /> Plant Capacity 1'✓r No. Units Served <br /> 7. ❑ LAUNDRY. For,July 1, -June 30,19 <br /> SIZE: ❑ Less Than 1.000 Si ❑ More Than 1,000 Sq. Ft. <br /> DRY CLEANING,Chemicals Used/Amount/MO.• <br /> EIRgBt+'R@F9FIiF1Bpr �gQnttt`9t+iaa;alyr�fflfi�iiastft (pllttt'I!ts!tilt;erllifrthatInthoperlormAltesc(thework'orwhichth#s0ormltIsissvoiIS`al►no!erp!oyami,00.1bii- <br /> ,!''II 861 h-009 ,H.e beag t!@$Lb.165 It.t9Pfk!ila�6 fa!tt.@!iEat10f1 IAt+.'s nI Gr)Ifor"i •" <br /> gn:c6e{nr s {trip p st b pn{ra{tiRB st'natt r.,� ,figs the foliea'inq: "I eorllly•that In 06 performance of the work for which this ra;mit is issued,I shall�!��g�Sgt§erg��p�B�E��ief!�nia�s ce�rpe!is,t;en �Calirarni� <br /> I hereby certify that I have prepared this application and that-the-vi will-be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules and regulationsofthe San Joaquin'Local Health District. IF <br /> APPLICANT'S SIGNATURE X <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 /> BASE EXPLANATION BILLING REMITTANCE $ <br /> ,[ DATE _. DATE REMITTED AMOUNT DUE CHECKED <br /> _ - AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - - r <br /> PLUS • <br /> 69 1 <br /> PENALTY <br /> OTHER <br /> - y. .. r. - - Ei.►..••tea y/... �„� +/ -/ <br /> OTHER <br /> Received by Dale Receipt No. I Permit No. I ante D leMalted Delivered <br /> APPLICANT'­� ETUR <br /> RN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AYE.,P.O.Bos 2008 STOCKTON.CA 9520V <br />