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` Applications Will Be:Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> - APPLICATION <br /> t- (For Non-Transferable, Revocable, and Suspendable) <br /> K ENVIRONMENTAL HEALTH PERMIT SEI'TAGE <br /> LIQUID WASTEw�- <br /> A Iications hereby-made to carry on business in the jurisdictional area of then Joaquin Local Health District <br />` w Business Name (DBA) N_�=L� l�I� Address <br /> a Owner 4, 1_ 1 �/%%E� Address f�4'24� Z,� � til-,L D <br /> --��_-� <br /> J Firm Partners, Addresses and Telephone Numbers _ <br /> a. Business Telephone No. -,r Emergency Telephone No. 1 <br /> Contractor Licence No. C �- <br /> L Applicants Name (Print) G <br /> Title AA.. /1/4=11p— Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> I For July 1, June 30, 19. Disposal Sites <br /> Description(Make/Yr., Color) z <br /> Serial No. ( CAL. License No. CAL. Lac.,-.se Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> f_ <br /> . 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> r No. of Vehicles Stored <br /> No. of Chemical Toilets.Store_d <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name f R.S. or R.C.E. No. - <br /> (!u <br /> Test Location �s Test Date/Time <br /> 4. •❑ SANITATION PERMIT <br /> Job Addre ✓++�' �_ _ <br /> � (� <br /> ss/Location <br /> Owner "" Address 9 �� <br /> t ❑ PACKAG PLANT O <br /> I�SEPTIC TANK ❑ CESSPOOL. LEACHING FIELD ❑ SEEPAGE PIT C <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER 1 <br /> 5. r❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction' Disposal Site F <br /> No. of Units Equipment Storage/Cleaning Location(s) • A <br /> 6. '❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> +` Operator Name Where Certified_ <br /> Plant Location <br /> Plant Capacity �' ' No:Units Served <br /> fr 7. ;© LAUNDRY For July 1, -June 30, 19 ' ` .- <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft: G <br /> �. ❑ DRY CLEAN ING,.Chemicals Used/Amount/Mo. <br /> I t I hereliycertify that I have prepared his application and that the.work'will.be don e"in ccordance with San Joaquin County <br /> i ordinances, state laws, and rules a re tions of the San Joaquin Local Health District. .- <br /> APPLICANT'S SIGNATURE X <br /> F- k FOR-DEPARTMENT USE ONLY + <br /> Fee Is Due: ❑ ANNUALLY- ❑-PEhI UNIT JkPER SITE_ ❑ EACH -❑ January 1 &Receivedl8 January,31, ❑ July 1 &Received By July.31 <br /> '- REMIT <br /> j ;r-. BILLING REMITTANCE $- AMOUNT DUE CHECKED <br /> +� ti: BASE. +'EXPLANATION <br /> ,�„ T DATE DATE REMITTED AMOUNT ' <br /> t, / <br /> I1 ESS l� '. <br /> PRORATION : <br /> ,i PLUS 1 <br /> I PENALTY ! <br /> - 2 <br /> OTHER <br /> Received by Date - Receipt No. Permit No. Fgsuand a Date Mailed Delivered _ <br /> k <br /> q, <br /> 'STOCKTON,CA <br /> APPLICANT—RETURN ALL:COPIES TO: , ENVIRONMENTAL HEALTH PERMIT/SERVICES . 1601 E.HAZELTON AVE.,AVE.`P.O.Box 20091 <br />