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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 /> d a'` ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LI' <br /> ( LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA) 40!F- Alli b'.d/f/ 4 50AI Address P.a !/O ,AToe/&S To <br /> 4 Owner A �� /3/Lz-&/��i Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> o. Business Telephone No. ✓��`'�— `��/ 5 Emergency Telephone No. <br /> Contractor Licence No. 416 - -5—e6 <br /> L Applicants Name (Print) e c 9^,7A only Title 67 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 Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. 1. <br /> Test Location Test Date/Time <br /> 4. )? SANITATION PERMIT <br /> Job Address/Location '4"7' y�l 1 /SI;s-60w px' <br /> Owner 72-e Y AOl'9 &P-->-2- Address -714AI e ell <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <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. 1 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. C <br /> 0 <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.,w lations 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 ❑July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> 4 AMOUNT <br /> FEE ✓ �: Q <br /> LESS <br /> PRORATION <br /> PLUS wRR <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 0 1-7 83 <br /> -7 9 gam 9/t 1W?y <br /> Received by Date Receipt No. Permit 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 />