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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 /> � ' ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE r <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District 1 <br /> OF Business Name (DBA) Address <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> Do'. Business Telephone No. &S-a ?7/ Emergency Telephone No. f <br /> Contractor Licence No. 4PS3 <br /> E. L Applicants Name (Print) FL-6)e-D I/Q490P l Title 6­1A1AoQ Date I Z -2- <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> II 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, - June 30 19 Disposal Sites `( <br /> Description(Make/Yr., Color) _ I <br /> Serial No, CAL. License No. CAL. Lic;:nse Renewal No. <br /> Capacity Gal.,Weights & Measures No. ' <br /> Equipment Parking Address ( - <br /> 2. ❑ PUMPER YARD i <br /> For July i, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> S <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.Name i R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. N SANITATION PERMIT <br /> Job Address/Location 00 A?D <br /> Owner Address 1034, ALI, kJ24-- 7 7' G Ta <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD P1 SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> . G <br /> Type Construction Disposal Site n <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 "s� 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 prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulati s o he San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X" <br /> C) <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &ReZ.dBV uary31 ❑ July 1 &Received By Juiy 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE - EXPLANATION DATE DATE REMITTED -AMOUNT DUE CHECKED <br /> AMOUNT <br /> j- FEE <br /> LESS 1 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER # - `� <br /> OTHER I <br /> Received by Date Receipt No. Permit No. Issuarce D Mailed Delivered ]/ <br /> APPLICANT—RETURN ALL COPIES TO: .ENVIRONMENTAL HEALTH PERMIT/SERVICES, 1501 E.HAZE1 TOIC A V114.O.Box 2009 STOCKTON,CA 95201 ` <br /> r <br />