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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. r <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> j <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE 00 <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> r Business Name (DBA) A .�'�,� s S�,ds i� Address P&�xIL/ OO ,-a-o/ <br /> i z Owner - <br /> t a Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. (a - 6 a-7 <br /> a a Emergency Telephone No. <br /> Contractor Licence No. 3 3 <br /> L Applicants Name (Print) D L�Jdo Title ESTi�strs� Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information s <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) _ <br /> For July 1, June 30, 19 Disposal Sites <br /> Make/Yr <br /> Description I <br /> p ( ., 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 /> r <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 l <br /> 4. SANITATION PERMIT I <br /> Job Address/Location 04 v F -S--77 <br /> Owner uIG I- . Ts+ C- OAJ Address <br /> �❑sSEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> �l PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> i ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. E] PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name t Where Certified <br /> Plant Location 4 <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 /> ) <br /> F <br /> 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 rules and regulations Joaquin Local Health District. 1 <br /> APPLICANT'S SIG TURF <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 /> BILLING R ITTANCE g REMIT <br /> BASF ANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE ` y <br /> LESS <br /> f <br /> PRORATION <br /> i <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r <br /> Received by Date �jReceipl No:' Permit No. Issuance Date Mailed Delivered 1 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 452 _ <br />