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NppimanonsWill BeProcessed When Submitted Property Completed. Be Sure To Sign The Application, <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> ApplicaYio s e eby ode to car on b I ess in the juAsdiocional area of the San Joaqui Lo ealth Digtrict <br /> F <br /> Business Name (DBA) �[-,1��5 C, Q Jx� /�Q R U �{ y <br /> a Owner 11Th ARr-t Address LS ! C <br /> Address <br /> Firm Partners, Addresses and Telep a Numbers C+� <br /> aBusiness Telephone No, 23^ <br /> Contractor Licence No. SI aJq/ }7 Emergency Telephone No. I <br /> a <br /> Applicants Name (Print) <br /> Please check Applicable ry(1-7)and Fill in the Required Informion <br /> Category Title Date <br /> at � <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. <br /> Capacity CAL. Licc e Renewal No. <br /> 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 Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST J <br /> R.S. or R.C.E. Name <br /> Test Location <br /> R.S. or R.C.E. No. , <br /> 4. 1:1 SANITATION PERMI �}7 Test Date/Time a <br /> ter- H <br /> Job Address/Location .�o`je' �l j�php `z <br /> Owner � T A611 qs� SA H- 39g ! zj <br /> Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL 13 LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW <br /> ❑ REPAIR ❑ OTHER <br /> 5. 11 CHEMICAL TOILETS For July 1, -June 34, 19 <br /> Type Construction Disposal Site 00 6 i5 p-6 <br /> No. of Units /�� �� 7#4*-* �r �fec G,r�j,l <br /> Equipment Storage/Cleaning Location(s) /I►I!L4 a0 <br /> 5. 11PACKAGE TREATMENT PLANT For July 1, -June 30, 19 r <br /> Operator Name <br /> Plant Location Where Certified <br /> Plant Capacity <br /> No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 5q, Ft. + <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 1 <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 regulations of the San Joaquin 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 13 July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS <br /> PRORATION <br /> } PLUS (�D <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received bypate Recei 1 No. 1 �U Z� <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT Si:RIVICES o. Issu ce Dae Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />