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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 t <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) _ RA RA -1 X1 -J��AI-T - Address OPO lS /' O 5'T. A/ 9s'a®f <br /> `z Owner Address <br /> a = <br /> j Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. - <br /> L Applicants Name (Print) F!-e S/7a LA)C"JO Title <br /> STIM.ATa_ Date <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 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. W <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. ❑ SANITATION PERMIT <br /> Job Address/Location_78 Q3 W. 13'115& R r 7YZ�Y <br /> Owner Fi2AA,;9 d S 4E, At 454 597V Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> J� PERMANENT ❑ TEMPORARY ❑ NEW REPAIR OTHER S-thOP <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 I <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning'Location(s) <br /> 6. 0-PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served f <br /> 7. ❑ LAUNDRY For July 1, -.tune 30, 19 I . <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 j <br /> ordinances, state laws, and rules and regulations of th oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> v S <br /> FO DEPARTMENT USE ONLY �k <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑'EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 1 <br /> OTHER <br /> Its <br /> /0 <br /> —'7 G -� l o ti z C. <br /> Received by Date - Receipt No. Permit No sauance Date Mailed Delivere <br /> APPLICANT—RETURN ALL cOPIEs To: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601'E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 ' <br /> r <br />