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"Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.t t <br /> APPLICATION NMEN�At HEALTH <br /> M a rad,, (For Non-Transferable, Revocable,and Suspendable) SEPTWl?'0 ERV1Ct� <br /> S'ta-�es Sw�`a ENVIRONMENTAL HEALTH PERMIT pERMRTIs <br /> LIQUID WASTE <br /> Application--Is�hereby made to carry opj2usiness in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name (DBA) �t►tr b <br /> e—c- � �Azz Address 32 w e_I h1 — L*d: c(S-Z-4 <br /> a Owner---%I • N as "ke- Address(moo 3p x U <br /> 10034 S+.�1c-��,.., QS'2kC <br /> J Firm Partners, Addresses and Telephone Numbers 23 b.! �l r►1—L e r" ^" �lo�GG �� <br /> a. Business Telephone No. or" 19 Emergency Telephone No. <br /> Contractor Licence No. _ <br /> L Applicants 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 <br /> No. of <br /> Chemical Toilets Stored <br /> y� <br /> 3. 4 PERCOLATION TEST � A <br /> ,R-S—w R.C.E. Name T2 c-,^.a r '� Ifi+2 2.Q— R-S-er R.C.E. No. SQL 3 QtJ� 8`� —11 1� <br /> Test Location .S2 Test Date/Time <br /> 4. 10N PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER •7 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units _ Equipment Storage/Cleaning Location(s) <br /> 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 hereby certify that I have prepar is application Apd the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rule d regulations a San J aquin Local Health District. <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> Q, AMOUNT <br /> FEE T <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ( � Ll rz-��sr 97ro CT <br /> Receive by Date Receipt No. Pe mit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />