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" Qplications WIII Be Processed When Submitted Properly!ofnpleted. Be Sure To SignTheAppucauon. <br /> APPLICATION_- <br /> ' (For Non-TrdnL�==6, Revocable,and Suspendable) $EPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> H Business Name (DBA] 45 Hildreth lane <br /> Address—.4-6 <br /> i Owner <br /> T. Donald Address. Sdn1P_ <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers �� <br /> abusiness Telephone No. 931-n497 Emergency Telephone No. g57— � _ <br /> Contractor Licence No.----31) <br /> Applicants Name (Print) Title ppr 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) CAL, Lic-ase Renewal No. <br /> Serial No. CAL. License No. ` <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> 4 <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. No. <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT �7 _ <br /> Job Address/Location �J <br /> Owner _ A drs <br /> ❑ SEPTIC TANK CESSP L ❑ LEAC FIELD ❑ SEEPA PIT PACKAGE PLANT ' <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR' ❑ OTHER w <br /> 5, ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site N ' <br /> No. of Units Equipment Storage/Cleaning Location(s) �. <br /> 6. 0-PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location 7 <br /> Plant Capacity No. Units Served _r <br /> 7. ❑ LAUNDRY For July-1, -June 30, 19 <br /> 1 000 S . Ft., <br /> ❑ More Than 1,000 Sq. Ft. <br /> ❑ Less Than q <br /> SIZE: � _ z <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t <br /> I hereby certify that I have prepared this application d that the work will be one in accordance with San Joaquin County <br /> ordinances, state laws, and les regulation�Of6e n Joaquin Local He �Distrlc�t <br /> 4•. <br /> APPLICANT'S SIGNATURE X p <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> iBy <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑-EACH El January 1.R Received By January 31 ❑ July 1 &ReceivREMITuIy 31 <br /> i BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> 0 �s <br /> LESS } <br /> PRORATION <br /> . PLUS SfSf <br /> i <br /> PENALTY <br /> r <br /> OTHER <br /> OTHER <br /> Receipt No. Permit No. I uance�Date Mailed Delivered <br /> Received by Date �� P <br /> .1801 E.HAZELTON AVE.,P.O.Bos 2099 //},,,�STOCKTON,CA 95201 ` <br /> - 'APPLICANT�RETURN ALL COPIES TO:"�•ENVIRONMENTAL HEALTH PERMITlSERYICES A _ _` g-2/-g d4 <br /> r ��GH� <br />