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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 h y made to Wry on busi ss int the jurisdictional area of the S Joaquin Local Health D' Ict <br /> ,�Business Name A) - Address o 7� �. <br /> aOwnerAddress <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. .2 tZ <br /> L Applicants Name (Print) Title Late 10 <br /> Please check Applicable Category(1-7)and Fill in the Requl Information Vl)'` <br /> j 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) v <br /> s.. w?4 ' <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. { CAL. License No. CAL. License Renewal No. <br /> Capacity ` - , 1�-_ `14 } G61.', Weights & Measures No. <br /> Equipment Parking Address # <br /> 2. ❑ PUMPER YARD } <br /> r 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. f <br /> f <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> 4` <br /> Job Address/Location Q.�a 2 •^-tom <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD T OVPACKAGE PLANT <br /> E ❑ PERMANENT ❑ TEMPORARY ❑ NEW SRL' AIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30 19 All <br /> Type Construction . T, Disposal Sit,k+ T. L " "`r'" <br /> Ir <br /> No. of Units Equipment Storage/Cleaning Location(sr) A` " <br /> 6. ❑ PACKAGE TREATMENT,PLANT For July 1, -June 30, 19 <br /> Operator Name }- • 'f' Where Certified <br /> Plant Location = I '! t <br /> Plant Capacity:, 14 No. Units Served fr/' <br /> 7. -❑'LAUNDRY For July 1,-June 30, 19 x <br /> SiZE: s�❑TLbss Than 1,00 SO SO q: Ft.,g`� ❑ More Than 1,000 Sq. Ft. A- 1 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> f <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 the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 1 <br /> a i <br /> i FOR DEPARTMENT USE ONLY 1f <br /> Fee Is Dile: ❑ ANNUALLY El UNIT ❑ PER SITE 11 EACH El January 1 &Received jiajuary 31 ❑ July 1 &ReceNe�y July 31 <br /> Cr BILLING REMITTANCE REMIT i <br /> BASE EXPLANATION PATE DAT RE*1EIl AMOUNT DUE CHECKED <br /> AMOUNT <br /> EEE 5 O7TI- <br /> 7---c <br /> LESS <br /> PRORATION <br /> PLUS 1 <br /> PENALTY - 1I <br /> OTHER - 1 <br /> OTHER - <br /> W. Received by Date Receipt No. Permit No. _ Is uance D te Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,P.O.Box'2009 STOCKTON,CA 95201 <br /> � i <br />