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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sigl�,.The AMplication. _ <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicati is hereb made to carry n busines jn the jurisdictional area of the San Joaquin Local Health District <br /> N Business Nage (DBA) nLt- Address <br /> aOwner j lt1 eHU..I Address <br /> Y Firm Partners, Addresses and SI p oneiNumbers <br /> IL Business Telephone No. " � C68 IV Emergency Telephone No. f-1 <br /> 1 Contractor Licence No. 2(439f'3 # l <br /> Applicants Name (Print) <br /> -T" %, - Title Date <br /> r <br /> Please check Applicable Category (1-7)and Fit in the Required Intormaiion. <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) bj <br /> For July 1, June 30, 19 1 Disposal Sites <br /> Description(Make/Yr., Color) j <br /> Serial No. CAL. License No. CAL, Licc7,se Renewal No. <br /> Capacity Gal !Weights & Measures No. <br /> Equipment Parking Address E� <br /> f 2. ❑ PUMPER YARD j <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stared <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 PERM�T/t� I _ <br /> t <br /> Job Addre /Location T /09 1 i eATN ^� ml9a'' � a a� <br /> t Owner 9! 0 McAd JAq A Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT -� <br /> r <br /> ❑ PERMANENT ❑ TEMPORARY 1 ❑ NEW REPAIR OTHER <br /> ' 5. ❑ CHEMICAL TOILETS For July ,1 +-June 30, 19 <br /> ! � <br /> Type Construction Disposal Site Ami A&D /0 <br /> ` No. of Units Equipment Storage/Cleaning Location(s) <br /> ? 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name I Where Certified <br /> Plant Location �4 <br /> Plant Capacity No. Units Served ]� <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> i SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> i ❑ DRY CLEANING, Chemicals Used/Amount/Mo. . <br /> I <br /> I hereby certify that I have prepared this application a d that the work will be done in accordance with San Joaquin County' <br /> ordinances, state laws, and s and regulali ns of th n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X C . <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT 1.7 PER SITE ❑ EACH ❑.January 1 &Received By January 31 ❑ July 1 &ReceivedByJuly 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 5� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> ' OTHER <br /> OTHER <br /> t _ <br /> c� a3 RD <br /> Received by oate Receipt No. Permit No. I Issuance D e Mailed Delivered <br /> 1 APPLICANT—RETURN'ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1sol E.HAZELTON A .,P.O.Box 2009 STOCKTON,CA 95201 <br />