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3 ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION _ <br /> r (For Non-Transferable, Revocable,and Suspendable) +� <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE'• <br /> LIQUID WASTE <br /> { Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health Disti <br /> i UF) BusinessName(DBA) . 'C:•l=���� <br /> c Owner Address trL <br /> "L'G��� Address- <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No, I Fir <br /> Contractor Licence No. 7 Emergency Telephone No. r <br /> L Applicants Name (Print) —,1101 di!r <br /> Please check Applicable Category (1-7)and Fill in the Required Information Title .�f17.UliIC>72. Date <br /> i 1• ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 <br /> Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. <br /> GAL. License No. -'0' �`*+y.� CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures IJo. <br /> Equipment Parking Address _ � <br /> 2. L1 PUMPER YARD " <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored iI <br /> No. of Chemical Toilets Stored fL <br /> 3. 1:3 PERCOLATION TEST___11l .•� <br /> R.S. or R.C.E. Name <br /> Test Location <br /> R.S. or R.C.E. No. <br /> � <br /> 4• ❑ SANITATION PERMIT Test Date/Time <br /> Job Address/Location 7_dt:_1A7 J__ �u .�� X, <br /> Ow c— j <br /> �,� h =}Address !¢�L <br /> 'SEPTIC TANK ❑ CESSPOOL EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEWff REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 31 s ,, <br /> Type Construction Disposal'Site s <br /> No. of Units Equipment Storage/Cleaning Locations) �• <br /> Y� # <br /> fi. El PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> -�,..e s,,, :. <br /> Operator Name � :11, � Where Certified <br /> Plant Location „ <br /> Plant Capacity <br /> No, Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 "�'` 4• .. , <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 11 Ill Than 1,000 Sq. Ff:j% ;' + <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 14 <br /> T ,yi <br /> I hereby certify that I havb.prepared this application and that-the work will be done in accordance with San Joaquin Count <br /> ordinances, state laws, and rules and regulations of the'Sar Joaquin Local Health District. ,_" y <br /> APPLICANT'S SIGNATURE X !fG <br /> j-.ice" ,•-. ---�.. „»..-. -�».�.. ,� ...�. _ �' ^ ,! <br /> FOR DEPART T USE ONLY ti <br /> Fee Is Due: ❑-ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EAC <br /> • ❑ January 1 8 Received By January 31 July 1 8 Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCEREMIT <br /> DATE DATE" REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> LESS <br /> PLUS _ <br /> PENALTY <br /> J - <br /> OTHER <br /> OTHER <br /> r <br /> Received by" Date Receipt No. Permit No. C I <br /> APPLICANT-RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PERMIT/SERVICES Issuance Date Mailed Deliveretl � <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 •STOCKTON,CA 95201 r <br />