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Applications Will 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 />n Application is ereby made o car pon b siness in th juris ictionai area of the San Joa uin Local Health District <br />c y Business Name (D ) �6 <br />a Owner �I? Addr ss- r�Q <br />Address-->�. <br />Firm Partners, Addresses and Telephone Numbers <br />Business Telephone No. "7 <br />( Contractor Licence No. Emergency Telephone No. <br />F .. L Appkicants Name (Print) <br />Ian Please check Applicable Category (1, and Fill In the Req red Information Title Date l - �—�Ci <br />t. ❑PUMPER VEHICLE PERM ITjREGISTRATION (FOR EACH VEHICLE) <br />For July 1, June 30, 19 I Disposal Sites <br />' Description (Make/Yr., Color) <br />Serial No. CAL, License No. <br />Capacity CAL_ Uccnse P.encwal No. <br />Gal., Weights &Measures No. <br />Equipment Parking Address ,------------- <br />r 2. ❑ PUMPER YARD <br />For July 1, June 30, 19 <br />r No. of Vehicles Stored <br />No, of Chemical Toilets Stored <br />3. ❑ PERCOLATION TEST <br />R.S. or R.C.E. Name <br />Test Location <br />R,S, or R.C.E. No. <br />¢• ❑ SANITATION PERMIT Test Date/Time <br />Job'Addr s/Location A 5 7 �2-1 Y\ <br />t ,O,w r dY "�y�Address S/ <br />S •FTIC TANK ❑ CESSPOOL <br />ACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br />k PERMANENT ❑ TEMPORARY l7 NEW ❑ REPAIR ❑ OTHER <br />5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br />Type Construction <br />Disposal Site <br />No. of Units Equipment Storage/Cleaning Location(s) <br />ti. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br />Operator Name ! <br />Plant Location Where Certified <br />Plant Capacity <br />_. 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/AmounVMo. <br />i • <br />! A <br />ti <br />-44' I hereby certify that I have pr <br />+.L ordinances, state laws, and rul <br />._ APPL4CANT'S SIGNATURE X <br />I <br />r.ee Is Due: 13 'ANNUALLY © PER UNIT <br />BASE <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />(1p' <br />this application and that the work will be done in accordance �wlth San Joaquin County <br />egulat j�s o . e y5,a� n Joaquin Local Health District. <br />FOR DEPARTMENT USE ONLY <br />El PER SITE CI EACH ❑ Jan ry 1 <br />1 r <br />EXPLANATION BILLING REM!TTAI <br />DATE DATE <br />Lrceived By ianjory 31 ©July 1 R Received By July 31 <br />$ REMIT <br />REMITTED AMOUNT DUE CHECKED <br />9 vs- <br />imn Issuan Date' Mailed <br />APPLICANT—RETURN ALL COPIES TO: EN'VIRONMENTAL EALTH PERMITlSERVICECES Delivered <br />1., <br />1801 E. HAZELTON AVE., P -D, Box 2009 ; STOCKTON, CA 95201 <br />