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ApplicationsWill Be Processed When Submitted Properly 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 /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name(DBA) 1!5, � <br /> �,, 41,77h&e ,F 5p4 <br /> Address Bax !1 I^✓ /�f��os�'e Gy 9ar3�3 <br /> Ii Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> o.a Business Telephone No. Si.7/ <br /> !66 " �' Emergency Telephone No. <br /> Contractor Licence No. ,PG <br /> L Applicants Name (Print) <br /> p(� <br /> Please check Applicable Category(1-7)and Fill in the Required Information Title Date <br /> t• ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I 4 <br /> k <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) ..1 <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal„ Weights & Measures No. <br /> f Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No, of Vehicles Stored F <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 1 Test Date/Time <br /> 4. 19 SANITATION PERMIT �1 <br /> Job Address/Location 8 4110-C16 4441, 11"y19G <br /> Owner Address <br /> ® SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 10 NEW ❑ REPAIR Off OTHER <br /> 5. Cl-CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> B. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name <br /> Plant Location Where Certified <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 ru s and regulations of the San Joaquin Local Health District. <br /> .APPLICANT'S SIGNATURE X ,��/ �/ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY a. ❑ PER UNIT ❑ PER SITE ❑"FACH - ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 s <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE, AMOUNT <br /> t� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 153a <br /> Received by D to 'r Receipt No. Permit No. Issuance Date Mailed <br /> - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES . 1601 E.HAZELTON AVE.,P.O.-Box 2009 STOCKTON,CA 95201 <br />