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mppllcaitons wm ese Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> _ APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicationis hereby madp to carry on siness in the ju n Local <br /> //d�dictional area of the San Joaquin Health istrict <br /> rn Business Name BA)_ - Address � ivir�G `7 , - � <br /> 2 <br /> a Owner Address n <br /> 9'���4— <br /> J Firm Partners, Addresses and Telephone Numb rs <br /> a. Business Telephone No. JL,�i S�/C' Emergency Telephone No. <br /> Contractor Licence No. 2-� <br /> Applicants Name (Print) - TitleDate <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> I. ❑ 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. Liccnise 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 L906 Test Date/Time <br /> 4. L"J SANITATION PERMIT <br /> Job Address/Location <br /> Owner -tet'-� iia t''�!✓' Addresss,� 1/%a <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD IJ SEEPAGE PIT 1:1PACKAGE PLANT U11)❑ PERMANENT ❑ TEMPORARY 13NEW WIREPAIR ❑ 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) d <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 m <br /> Operator Name Where Certified l <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 rl and regulations f te San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE XFOR 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 /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 4r <br /> LESS - <br /> PRORATION Is <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> j c � � <br /> Received by Date Receipt No. Permit No. 1-4jance Owe Mailed Delivered <br /> • APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON_CA c57n1 _ <br />