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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 /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) I Address .®2&aZ 3 .444rw, f'd.t'ee I <br /> a Owner 7>lew Address •+re. <br /> Firm Partners, Addresses and Telep one Numbers . <br /> 0. Business Telephone No. ( _ Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title 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 r <br /> Description(Make/Yr., Color) <br /> Serial 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 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 <br /> Owner /C Address vRAG23 /*49tyq04W <br /> ❑ SEPTIC TANK CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER R , <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 �J <br /> Type Construction Disposal Site <br /> No, of Units Equipment Storage/Cleaning Location(s) Cna <br /> 6. ❑ PACKAGE TREATMENT PLANT For!July 1, -June 30, 19 <br /> Operator Name I- _ 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/AmounilMo. ' <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, rules and regulations of the San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY %�2 +mer <br /> Fee IS Due: ❑ ANNUALLY _Q PER UNIT ❑ PER SITE ❑ EACH- I] January 1 &Received By January 31 ❑ July 1 &Received By July 31 II <br /> �I <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHEGKEl7 <br /> AMOUNT <br /> rEE 'AT AfI <br /> PRORATION <br /> PLUS f <br /> PENALTY <br /> OTHER pifil 4 4 <br /> TU <br /> OTHER it k <br /> 3 69 <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.Box 2009 STOCKTON,CA 95201 i <br />