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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> f { (For Non-Transferable, Revocable,and Suspendable) l <br /> / <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> `7`0 LIQUID WASTE <br /> Applicati I�j�je �r/y�de to ca�^on mess inpe jurisdictional area of the San Joaquir�-J,Zbocal Health Dis rict <br /> WF Business Nau;IFL!'DBA) i l\ ILC (_ "t� C� C'/L Address /SU rJC3-1701U Ave <br /> 4 Owner m �RG1/� Address <br /> j Firm Partners, Addresses and Telephone Numhws <br /> a Business Telephone No. W23- Sg y Emergency Telephone No. <br /> Contractor Licence No. .241.3 91 4 <br /> L Applicants Name (Print) Title 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 r. <br /> Description(Make/Yr.,Color) -� <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 <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. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERUET <br /> Job Add ressff Location 0000 /<,ISS eAj R 0 <br /> Owner L,C>L 5 PA40RIC 14 Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW eREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 _ <br /> Type Construction Disposal Site __P��r9c� �X�ST/�y R�'O tN t>37 T �J I I H <br /> No. of Units Equipment Storage/Cleaning Location(s) 1-26Q G C C-A<t%ek. <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. <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 regulaptionsOft San Joaquin Local Health District. <br /> lQ� <br /> APPLICANT'S SIGNATURE X <br /> 7y,,Lfi.kt <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Januar 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITT $DATE DA REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION IV <br /> PLUS <br /> PENALTY Al <br /> OTHER All" i0_1 <br /> OTHER <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 />