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Applications Will be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION , <br /> v (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is P&Pby m�de�to car n business' he jurisdicti al area of the Sqxqoaquin Local Health District! <br /> y Business Name (D ) ddress 6 7 <br /> x a Owner Address <br /> Firm Partners, Addresses and TelephonelNumbers <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print)' } Title — .. Date Z Rib I <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1. .0'PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I <br /> For.,July —. June 30, 19 Disposal Sites { <br /> A <br /> Description(Make/Yr., Color), <br /> SeriakNo_.y"'ll" 3 CAL:License No. CAL'License'Renewal No. <br /> Capacity L Gal.�Weighats& Measur�els No. <br /> Equipment Parking Address / �G+ "�" a . <br /> 2. ❑ PUMPER YARD <br /> For July 1, 4 June 30, 19 <br /> No. of Vehicles Stored �. <br /> No. of Chemical Toilets Stored <br /> k 3. ❑ PERCOLATION TEST 1 <br /> I, R.S. or R.C.E, Name R.S. or R.G.E. No. G <br /> Test LgL�ation Test Date/Time <br /> 4. 9 SANITATION PERMIT ....1 G <br /> Job Address/Location Z $3 73 - - <br /> Owner ).�--+� �.*-p�� Address 4141 _ <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD EPAGE PIT ❑ PACKAGE,PLANT <br /> k ❑ PERMANENT ❑ TEMPORARY 1 ❑ NEW t U REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETSFor.July 1, -June 30,"`191 <br /> Type Construction 1 `�Disposal Site <br /> No. of Units. Equipment Storage/Cleaning Location(s) ' <br /> - <br /> 6. 11PAC_KAGE TREATMENT PLANT'IFor July 1, -June 30, 19 / 13 <br /> Operator Name F �*s Wfiere Certified <br /> Plant Location - <br /> Plant Capacity ! e No. Units Served t. <br /> 7. ❑ LAUNDRY For July,1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. •k -+- ^ <br /> f� r <br /> I hereby certify that I.have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws; and rules regulations of th Joaquin Local Health District. <br /> 1 •e;I f <br /> APPLICANT'S SIGNATURE X <br /> t <br /> I FOR DEPARTMENT USE ONLY ; <br /> I Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 my 1 & <br /> '�ijy July$i <br /> k r r REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ M UIT DUEY' CHECKED <br /> i a -DATE DATE REMITTED AMOUNT <br /> i { <br /> FEE <br /> 1 6 <br /> LESS <br /> PRORATION <br /> PLUS F <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r - , <br /> CC <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> t f <br />