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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. y <br /> ® r APPLICATION <br /> t (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application I ereby ma�or_±LLry�y on b siness in the ju 'sdictional area of the San Joaquin Local Health District <br /> Business Name (DB +:�i �� , �« c Address ?G 7p c4 <br /> aOwner_. Address <br />` ° Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> 3. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. 7 9 Z - R <br /> L Applicants Name (Print) Title -� pale <br /> Please check Applicable Category(1-7) and Fill in the Require` 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. License Renewal No. <br /> Capacity. 3 *"' 'Gal., Weights &Measures No. <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 O <br /> O <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Dation Test Date/Time <br /> 4. Jn SANITATION PERMIT rr •� f"' f <br /> Job Address/Loc n 7DC 2 �G� •�f�` , ;; �` <br /> O er "� Address L�/ Ie+ <br /> j PTIC TA ❑ CESSPOO LEACHING FIELD SEEPAGE PITS ❑ PACKAGE PLANT <br /> L9 PERMANENT ❑ TEMPORARY 15 NEW ❑ REPAIR ❑ OTHER ,�ks ` <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 rff, ._.� % t> 79—L/- 7� <br /> Type Construction Disposal Site k x• F_�d <br /> No. of Units Equipment Storage/Cleaning Location(s) ) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified •�� 'I <br /> Plant Location to r , i -�-- —� <br /> s,4 i3..[ti l L t t <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 e <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> w <br /> I hereby certify that I have prepared this application and that the work will be done in accordanwith San Joaquin County <br /> ordinances, state laws, and rules and ulations of the Sa Joaquin Local Health District. i <br /> APPLICANT'S SIGNATURE X � <br /> I <br /> FOR DEPARTMENT USE ONLY Y <br /> .Feels Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 - <br /> k BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION # AMOUNT DUE CHECKED <br /> DATE i S DATE" REMITTED AMOUNT <br /> FEE <br /> �s <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i <br /> I <br /> 3sf a ! <br /> Received by - Date Receipt No. r1§5rmit No. Is�nce Dile Mailed De—livered,- <br /> APPLICANT—RETURN <br /> a vered,- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM;/SV ES' 16V E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> " - �1;7_5­/tea i' <br />