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kfppiications Will Be Processed When Submltted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> i ENVIRONMENTAL HEALTH PERMIT SEPPAGE <br /> I ,v LIQUID WASTE <br /> Applicati Is hereb m /d�e to carry busi�jes In the ju ' dlctional area of the S n oaquin cal�jp�alth District <br /> y Business N {DBA} �l� i �` I `K '.:� Address D v ( 4 4'Z-j /�V� <br /> I a Owner 1�'t d A&,/@ Address 'nC' <br /> J Firm Partners, Addresses and el ! one Num rte+ <br /> M Business Telephone No. 8 Emergency Telephone No. <br /> Contractor Licence No, <br />! L Applicants Name (Print) <br /> Title Date <br /> F Please check Applicable Categoryh(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 11 Disposal Sites <br /> Description(Make/Yr., Color) Ir <br /> Serial No. IIr CAL. License No. CAL. License Renewal No. <br /> i. <br /> Capacity Ir Gal., Weights & Measures No. <br /> Equipment Parking Address .Ipp1. <br /> 2. ❑ PUMPER YARD <br /> i 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 !I' R.S. or R.C.E. No. <br /> Test Location ip: Test Date/Time ,a <br /> 4. ❑ SANITATION PERMIT/O, <br /> Job Address/Location .3 U c- MC k)ojL15y, kAVe— - <br /> Owner 110 A '`q Address PO r• j C(' ysf [;c} <br /> Q <br /> 13 SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW Er <br /> REPAIR ❑ OHER <br /> 5. <br /> 11 CHEMICALTOILETS For JUly 1, -June 30, 19 r�Q <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 j <br /> Plant Location IM <br /> Plant Capacity IM No. Units-Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. 4', 11 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo, <br /> I <br /> I <br /> I • <br /> I hereby certify that I h,ve prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, Ind regu�tions ofe San Jo uin Local Health District. G <br /> APPLICANT'S SIGNATURE X 11� if✓�,� <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 /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> `i. DATE DATE REMITTED AMOUNT DUE CHECKED <br /> y AMOUNT <br /> FEE � 141 - <br /> LESS NMS <br /> PRORATION _ <br /> PLUS �k <br /> PENALTY r <br /> OTHER t <br /> OTHER <br /> Received y Dat I Receipt No. Permit N Issuance Date `Mailed Delivered f <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES . 1691 E.HAZELTON AVE.,P.D.Bos 2009 STOCKTON,CA 95201 <br /> 1 I <br />