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Applications Will Be Processed When Submitted Properly CompietedI <br /> APPLICATION Sure To Slgn The Application. r <br /> �--� <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is reby made to rry on business in the Uri di <br /> ctional area of the S Jo u <br /> asiness Name (DBA) in Local Health Distric <br /> z . <br /> rr _ Add s_..... <br /> a Owner — - •<,. <br /> Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. -�f n r --- — <br /> Contractor Licence No. Emergency Telephone No. <br /> ( ApplicantsN Name (Print?_ rO �c = 81 — _Q <br /> _ Title ___ _ <br /> Please check Ape C <br /> plicablategory(1-7) and Fill in the Required Inf rd motion Date -1 <br /> I. ❑ 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 /> — CAL. License No. _ - CAL'. License Renewal No. <br /> G _ - <br /> — <br /> Capacity _ j �_ al.,Weights� Measures NO. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD t <br /> For July 1, -_ June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST — +R.S. or R.C.E. Name _16R.S br R.C.E.No. <br /> Test L ation Test Date/Tirne - ; — <br /> 4. SANITATION PERMIT ,.�.,,rI <br /> Job Address/Location �16'H <br /> Owner_ � Addr s_❑ SEPTIC TANK ❑ CESSPOOL IELD C�' _Z <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW, ❑ ❑ PACKAGE PLANT <br /> REPAIR OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Construction {Disposal Site_ rr <br /> 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 '' *t� -- <br /> Plant Capacity- _ _ <br /> �-,.No, Units Served . k <br /> 7. ❑ LAUNDRY For July 1, -June 30.-19 "r — <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/AmounVMo. s <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 regulatioWofeSa Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X — <br /> FOR DEPARTMENT USE ONLY 1 <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER ❑ <br /> --- ---- __ SITE EACH <br /> _ El January i&Received By January 31 ❑ July 1 8 Received By July 3+ <br /> BASE EXPLANATION KILLING I REMITTANCE REMIT <br /> DATE DATE REMITTED <br /> - <br /> 3 AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS J <br /> PRORATION <br /> PLUS -._ <br /> -- r <br /> PENALTY � <br /> ETHER i <br /> OTHER <br /> .I <br /> Received by Date ._... er 1.. �J" O"�)""' <br /> Receipt No. Permit Nn -- esus ce pate Mailed —DBirvered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PF gVlCES - - 1 <br /> 1801 E.HAZELTON AVE.,P.O.Box 2009 - STOCKTON,CA 95201 1 <br />