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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 /> p 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 District <br /> „r Business Name (DBA) Address <br /> a Owner_ ?&N 5 }_Q1c lam. _ Address O rg a p. —�I Or _/VA2 o7el Otea <br /> k <br /> Firm Partners, Addresses and Telephone NLumbers <br /> 4 Business Telephone No. d 3' 311515 <br /> Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) ) sm X'P'- Title � � �'� Date to �1 <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. Liccnse Renewal No. <br /> CapacityGal., Weights & Measures No. <br /> Equipment Parking Address; r <br /> 2. ❑ PUMPER YARD Y ,t <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 PERMIT /(� _ <br /> Job Address/L cation— 1 ( � '" 5 ��'4 rP� CT- ' " Q'1 e'C('Le <br /> Owner -ernsS'1 x1 fi r Address 17 J�'- - a LC7" ah (7- ��f�n1 GCt,/ - i <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ EEPAGE PIT El PACKAGE PLANT <br /> 11 PERMANENT 11 TEMPORARY 11NEW REPAIR ❑ OTHEFI { <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) q� <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 1 <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. i <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 r nd regulations of the San oaquin Local Health District, <br /> I <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 /> BILLING REMITTANCE $ <br /> REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 41 L/ ys <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Q { <br /> /L — ,j — T.6j <br /> Received by Dae - Receipt No. Permil No.- Issuance Date 'Mailed Delivered <br /> APPLICANT—RETURN.ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 21309 STOCKTON,CA 952111 <br />