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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> i H PERMIT SEPTAGE ENVIRONMENTAL HEALTH�.< Q I <br /> ,S' ` <br /> AO ; LIQUID WASTE -?-1 3— ��n -sem <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 /97 JAR La.. A• !z if A � <br /> aOwnery LQG f L �_44.rfAddress A— - <br /> u Firm Partners, Addresses and Telephone Numbers <br /> COL' Business Telephone No. Ft =f 17 47 Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) Title Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information <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 CJ <br /> No. of Chemical Toilets Stored �l <br /> 3. ❑ PERCOLATION TEST Q. <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. K SANITATION PERMIT <br /> Job Address/Location _6�& 67_a,!01-7-_41—hr Z ro Od 1 414;- r 7' CIS 9 4 9 6- 4-4P Q��``I - <br /> Owner /2i Ld s C Address t5" Z G 7°4 X <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD. ❑ SEEPAGE PIT ❑ PACKAGE PLANT �) <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER t � <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 � <br /> r Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) r <br /> Z 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! I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> i <br /> ordinances, state laws, and rules and regulations'of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> i <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 DATE REMITTED <br /> I� ,(�,, AMOUNT � <br /> FEE ` ! �,rO 1 <br /> LESS <br /> E PRORATION <br /> E PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> F Received by - - Date z Receipt No. - Permit No. issuance Date Mailed Delivered- <br /> 4" .. APPLICANT—RETURN ALL COPIES TO! ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2008 STOCKTON,CA 95201 - <br />