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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. I ♦ 1 <br /> APPL•ICAVON' Q ` <br /> --! <br /> if .on-Transferable, Revocable,and Suapendable, <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the Saa_lnaquin Local Health District _ <br /> q Business Name (DBA)_�.G=. uLG cY� Address rffe,, ��ti �</ �_,/�✓ 7 C'Q <br /> Owner ,A I jq� e e Address - <br /> L�+ Firm Partners, Addresses and Telephone Numbers 'I <br /> ` Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> 1 <br /> Applicants Name-(Print)��l 4 Zi � Title -��%-+-�`r'�— Date�—�0�- <br /> Please check Applicable Category (1-7)and Fill In the Required Information r <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19 � _ Disposal Sites <br /> r <br /> Description(Make/Yr., Color) - - — <br /> Serial No. CAL.License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. P PUMPER YARD <br /> For July 1, June 30. 19 <br /> No.of Vehicles Stored <br /> No. 01 Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST 1 <br /> R.S. gr R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION'PERMIT <br /> Job Address/Location_ �� a • r/1•-�� '�'-J`--�r �,1� <br /> Owner I - Addresss `��",',�,Ar�L <br /> ❑ SEPTIC TANK ❑ CESSPOOL EACHING FIE7 LD -- :FPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY Q'NEW PAIR ❑ OTHER - L <br /> 5. 11 CHEMICAL TOILETS For July 1, -JUne:30, 19 ����./ C>4 <br /> Type Construction Disp past Site C ' <br /> No. of Units Equipment Storage/CI'eani.pg Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19- <br /> Operator <br /> 0, 19•Operator Name _ Where Certified <br /> Plant Location , <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 rules an reguldtions of the$an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 405 - <br /> r FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT' O PER SITE ❑ EACH ❑-January I&Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION . DATE GATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> a } 00 <br /> FEE <br /> LESS 'r <br /> PRORATION <br /> PLUS <br /> PENALTY e/ /yam <br /> O <br /> OTHER � <br /> OTHER <br /> Received by Date Receipt No. Permit No. Assuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,P.O.Bo.TKOs STOCKTON,CA 9S201 <br />