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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION A} - -- <br /> (For Non-Transferable, Revocable, and Suspendable) I <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGI" <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> WT Business Name (DBA) H• A - P,4 /(V --0 Al Address POB�X / O ST.� YQ <br /> i Owner Address <br /> a <br /> zuFirm Partners, Addresses and.`Telephone Numbers <br /> m Business Telephone No.— `��6 ��� 7 Emergency Telephone No. <br /> Contractor Licence No. ,57413 3 <br /> L Applicants Name (Print) F=C&leD Wee D Title 46:57)s9A721-p- Date /D- <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 /> Seriai No, CAL, License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July i, June 30, 19 <br /> No. of Vehicles Stored <br /> rt <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. V SANITATION PERMIT <br /> Job Address/Location 11,XlotarY1 L0D <br /> Owner bkr-es ,�e- -T_-41Li S Address e 1 <br /> .q SEPTIC TANK 1VOCESSPOOL LEACHING FIELD g SEEPAGE PIT ❑ PACKAGE PLANT <br /> ET PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 Of <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 T <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 <br /> ordinances, state laws, and rules and regulations of th an Joaquin Local Health District. <br /> e <br /> APPLICANT'S SIGNATURE X <br /> FOR DEP TMENT 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 /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT + <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> «i <br /> PENALTY <br /> OTHER <br /> r <br /> 1 <br /> OTHER <br /> - G—9;1,`t <br /> Received by Dale Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA 85201 <br />