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"—° Applications Will Be Processed When Submitted Properly Completed.'Be Sure To Sign The Application. <br /> - <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT - 5EPTAGE <br /> LIQUID WASTE <br /> Application is hereby ma/de to carry on business in the jurisdictional area of the San Joaq in Local Health District _ <br /> y Business-Name (DBA) r ��rI✓lil��l1/S� f Soti - Address � <br /> z Owner E e ."gAlrhooel/ Address 5�_j^je <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. X23- `�i7� `l Emergency Telephone No. d' <br /> Contractor Licence No. <br /> Applicants Name (Print) A�° e �5a�v Title ��n'�7''u� 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 <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. A f <br /> Test Location Test Date/Time <br /> J � <br /> 4. 0 SANITATION PERMIT <br /> Job Address/Location - <br /> Owner C5 46-Vc AX-10A Address <br /> C9 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT, '❑ PACKAGE PLANT <br /> ® PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 . <br /> Type Construction Disposal Site J <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <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/Amount/Mo. <br /> 4 <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 rule 'an regulations of the San Joaquin Local Health District. <br /> r <br /> APPLICANT'S SIGNATURE X 1&1�4k <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> Fee Is Due: ❑ ANNUALLY PER UNIT El PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> EASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> } 1 r DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORAT4ON <br /> PLUS <br /> PENALTY <br /> OTHER 09wo <br /> a <br /> OTHER I <br /> Received by" I Date I 1 Receipt No. Permit No. Issuance Date Mailed DeUvered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />