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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />APPLICATION _Q� - <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 L <br />�, Business Name (DBA) P� A • PA.E,e/S,N Ar _-.o VS Address P0 -X -*X /5<S <br />aOwner Address <br />u Firm Partners, Addresses and Telephone Numbers <br />m Business Telephone No. e. —1760') Emergency Telephone No. <br />Contractor Licence No. aS413 'ye -a <br />L Applicants Name (Print) F't4tTo tOed flTitle -:S71 4: 720 -4 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 <br />Description (Make/Yr., Color) <br />Serial No. <br />Health District <br />Capacity <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 />CAL. License No. <br />Gal-, Weights & Measures No. <br />CAL. License Renewal No. <br />R,S. or R.C.E. Name R.S. or R.C.E. No. <br />Test Location Test Date/Time <br />4. V SANITATION PERMIT <br />Job Address/Location i1,2 fe /YJ1CXE�+�F7-,1QdiJ 7 !2D LDD/.. (14 <br />Owner 1- .GPP-IC`Ef� �- -TSA 1/t e Address /O/3 R 1d5R- r 67;]'s C Mn <br />.4 SEPTIC TANK ESSPOOL LEACHING FIELD Rr SEEPAGE PIT ❑ PACKAGE PLANT <br />PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br />5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 \\\ <br />Type Construction Disposal Site <br />No, of Units Equipment Storage/Cleaning Location(s) <br />6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br />Operator Name — <br />Plant Location <br />Plant Capacity <br />7. ❑ LAUNDRY For July 1, - June 30, 19 — <br />No. Units Served <br />SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq_ Ft. <br />❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br />Where Certified <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 rules and regulations of the San Joaquin Local Health District. <br />APPLICANT'S SIGNATURE X � <br />J. <br />V <br />f <br />N <br />FOR DEP RTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I & Received By January 31 ❑ July 1 & neceived By July 31 <br />BASE <br />EXPLANATION <br />BILLING <br />REMITTANCE <br />AMOUNT DUE <br />REMIT <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />--- <br />FEE <br />LESS <br />.�„•.��� <br />PRORATION <br />PLUS <br />PENALTY <br />r <br />OTHER <br />OTHER <br />; <br />g <br />_ <br />Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br />-PIES <br />...I iCANT RETURN ALL COPE TO ENVIR <br />ONMENTAL HEALTH PERMITiSERVICES 1601 E. HAZELTON AVE., P.O. Box 2009 STOCKTON, CA 95201 <br />