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Applications WIII 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 I <br />y Business Name (DBA) D, A • P�,E,B/s%� yr 5m,y� Address ""9'00'e lits <br />a <br />Owner <br />Address <br />Firm Partners, Addresses and Telephone Numbers <br />a Business Telephone No.. <br />k 6— 9& 0 7 <br />Emergency Telephone No. <br />Contractor Licence No. 'A 41-a'1C3 <br />Applicants Name (Print) =Lrr Yp &L. e0 D Title <br />Applicable Cate o Date <br />Please check A <br />Pp g ry (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 />Health District <br />Description (Make/Yr., Color) <br />Serial No. <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. 7I SANITATION PERMIT <br />Job Address/Location 1/2-lo1g I"Ja,eav rra �C 02D 1-19>Zi C44 <br />Owner %AS_�_51C,;R_c�-�T�Q���j S Address /O!3 R 1 t/V/p�n <br />.� SEPTIC TANK ESSPOOL LEACHING FIELD rc' SEEPAGE PIT ❑ PACKAGE PLANT <br />PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br />5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br />Type Construction <br />No. of Units <br />S. ❑ PACKAGE TREATMENT PLANT <br />Operator Name <br />Disposal Site <br />Equipment Storage/Cleaning Location(s) <br />For July 1, - June 30, 19 <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 than Joaquin Local Health District. <br />APPLICANT'S SIGNATURE X <br />/A /Ow X----.51 <br />• .•... nom....,,, . L� wn=C TO: ENviHUNNENTAL HEALTH PERIVIMSERVICES 1601 E. HAZELTON AVE., P.O. Boa 2009 STOCKTON, CA 95201 �' / <br />FORDEP RTMENT USE ONLY <br />Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I & Received By January 31 ❑ July 1 & Received By July 31 <br />BASE <br />EXPLANATION <br />BILLING <br />REMITTANCE <br />$ <br />REMIT <br />DATE <br />DATE <br />REMITTED <br />AMOUNT DUE <br />CHECKED <br />%rte <br />AMOUNT <br />FEE <br />r- <br />LESS <br />Al <br />PRORATION <br />= <br />�G•.��1., <br />t <br />PLUS <br />PENALTY <br />OTHER <br />r <br />OTHER <br />IF <br />-7 <br />Received by Date Receipt N. Permit No. Issuance Date Mailed Delivered f <br />• .•... nom....,,, . L� wn=C TO: ENviHUNNENTAL HEALTH PERIVIMSERVICES 1601 E. HAZELTON AVE., P.O. Boa 2009 STOCKTON, CA 95201 �' / <br />