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4 Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transierable, Revocable,and Suspendable) <br /> ENVIRONMENTAL.HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby m e to carry on usiness in the jurisdictional area of the San Joaquin Local Health Dist ict <br /> y Business N e (DBA) AddAV <br /> z Owner 1 G� Address es�� _ i /�� �+ � - <br /> 9 Firm Partners, Addresses and Telephone Numbers �R—u� ..f`f� 7'fT <br /> . Business Telephone NoEmergency Telephone No, cf/4'Z- <br /> _J Contractor Licence No.� 9 -7A <br /> L Applicants Name (Print) �� cs � Title ���� Date 46 <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 S <br /> Description(Make/Yr., Color) <br /> W <br /> Serial No. CAL. License No. CAL. UCL;ISe Pei No. <br /> Capacity 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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. WSANITATION PERMIT / �rr <br /> Job Address/Location �y7 � 60, 4czt'- <br /> Owner I � -��/LQirit+2_ Address <br /> 11 SEPTIC TANK 13 CESSPOOL DILEACHING FIELD 55 SEEPAGE PIT ❑ PACKAGE PLANT (,3 <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 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 apli and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, s d regula ns f t San Joaquin Local Health District. <br /> I <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> SASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT RETURN ALL COPIES TO - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />