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-=t ^ - - •, --to—vu. oe oure 10 Sign The Application. <br /> APPLICATION t, -tr <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> s LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DSA) <br /> Owner—��«}r ,(!� �t��IA�— Address <br /> _ Address 1l S 3a <br /> Firm Partners, Addresses-and Telephone Numbers - <br /> Business Telephone No. �•l-7 _. <br /> Contractor Licence No. Emergency Telephone No. <br /> Applicants Name (Print) <br /> Please check Applicable Category Title r' r• Date <br /> g ry{1-7}and FIII in the Required Information - 1 <br /> 1. ❑ PUMPER VEHICIE PERMIT REGISTRATION (FOR EACH VEHICLE) (/ <br /> For July i, __June 30,-19 Disposal Sites a <br /> Description (Make/Yr., Color)" <br /> Serial No. CAL. License No. — — <br /> Capacity` CAL. License Renewal No. <br /> Gal., Weights & Measures No. _ -- -- <br /> Equipment Parking Address _ <br /> 2. ❑ PUMPER YARD _ <br /> For July 1June 30, 19 <br /> No. of Vehicles Stored <br /> No..of Chemical Toilets Stored ` <br /> 3. ❑ PERCOLATION TEST <br /> _ ` <br /> R.S. or R.C.E. Name <br /> Te <br /> - R.S. or R.C.E. No. <br /> Test ocation <br /> 4• SANITATION PERMIT I`I-S7—o Test Date/Time -- <br /> Job Address/Location 1j <br /> ner ,LLC' /` ��1']I^Y7r^�lL I Address��4,L�• <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPOR_ARy ❑'NEW ❑ REPAIR ❑ OTHER <br /> i• ❑ CHEMICAL TOILETSRFor July 1;-June 30, 19 <br /> Fype Construction Z Disposal Site <br /> Jo. of Units _Equipment Storage/Cleaning Location(s) <br /> ❑ PACKAGE TREATMENT PLANT,..For July 1,_June 30, 19 — <br /> )perator Name <br /> Where Certified <br /> '[ant Location -- <br /> lant Capacity No. Units.Served - 7 <br /> ❑ LAUNDRY For July 1, -June 30, 19 - <br /> IZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft,} <br /> DRY CLEANING, Chemicals Used/Amount/Mo. <br /> , a <br /> I� <br /> I hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin County E <br /> ordinances, state laws n rules and r ations of the San Joaquin Local Health District. <br /> :IPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH <br /> January 1 d Received By January 31 ❑ July 1 &Received By Juiy 91 <br /> BASE EXPLANATI NJ I BILLING REMITTANCE $ - REMIT <br /> DATE DAT REMITTED AMOUNT DUE CHECKED <br /> FEE *47j� r AMOUNT <br /> LESS �(//"" <br /> PRORATION <br /> PLUS - <br /> PENALTY �- - <br /> OTHER - <br /> OTHER r <br /> Received,by Date Receipt No. ermd No, <br /> --- APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Issuance Date Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95201 <br />