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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> <y -� (For Non-Transferable, Revocable, and Suspendable) } <br /> ENVIRONMENTAL HEALTH PERMIT f SEPTAGE i <br /> LIQUID WASTE [ 3 <br /> Application is hereby made to tarty on b mess in the jurisdictional area of the San Joaquin Local Health Distri t <br /> rn Business Name (DBA)`1_IP- �BL—TtAP L� O E Address 7 5 n J%I C_L <br /> a Owner LEr_ lq L� 'PcL� Address <br /> Firm Partners, Addresses an Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No. t <br /> 3 Contractor Licence No. �--- <br /> L Applicants NamL�T�\RN` L_ Title Date L <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. Licznse Renewal No. I <br /> f � ; <br /> '^Capacity---~ -"—__ - Gal., Weights•&Measures-No.- - - - -------Cam <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 PER T r <br /> Job Addr ss/Location _ <br /> )� l <br /> Owner Address ' <br /> ❑ SEPTIC ANK ❑ CESSPOOL 2CLEACHING FIELD X SEEPAGE PIT ❑ PACKAGE PLANT <br /> E] PERMANENT. ❑ TEMPORARY LJ NEWRtPAIR ❑ OTHER <br /> 5. `❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site r ---�---- 7 <br /> No of Units Equipment Storage/Cleaning Location(s) <br /> 6. ":❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> c <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served�iT <br /> 7. t❑ LAUNDRY For July 1, -June 30, 19 r <br /> 41 <br /> SIZE: ElLess Than 1,000 Sq, Ft., 13More Than 1,000 Sq. Ft. <br /> t❑ bRY CLEANING, Chemicals Used/Amount/Mo. <br /> x <br /> I hereby certi I have prepared this applica on and that the work will be done in accordance with San Joaquin County <br /> _ ordinances, stat law d rules an. egu ti s the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> 4 r i <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH. "'.0 January 1 &Received By January 31 ❑ July 1 &Received'By July 3.1 <br /> w a BILLING MITTANCE y <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> r DATE DATE REMITTED AMOUNT <br /> FEE s <br /> f <br /> LESS <br /> PRORATION z 1 1 <br /> PLIESs _ 1 <br /> PENALTY • . <br /> ' z <br /> OTHER <br /> a OTHER <br /> 77C�4 _ <br /> - a r <br /> qH'I �-h'I OYV7 <br /> Received by I Date Receipt Nb. .r Permit No. - Issuance Date -Mailed D—err7ered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES" 1601 E.-HAZELTON AVE.,P.O.Box 2009 - STOCKTON,CA 95201 _ . <br />