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a 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 SEPIAGE <br /> _ LIQUID WASTE h <br /> �'-� pplication is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District a <br /> ,„Business Name (DBA) OAKWOOD LAKE , IN-C- Address 874 EAST WOODWARD AVENUE _MANTECA <br /> a Owner ROBERT H. BROWN Address 874 EAST WOODWARD AVENUE ,MANTECR <br /> Firm Partners, Addresses and Telephone Numbers <br /> a (20Telephone No. �'2fl Y2 9_g566 Emergency Telephone No. <br /> Contractor Licence ho. r <br /> Applicants Name (Print) _ ROBERT H. BROWN Title T Date- 6-6-80 W <br /> Please check Applicable Category (1-7)and Fill-in:the'Aequ'ired•Information I <br /> 1. C1PUMPER''VEHICLE PERMIT 9rrzdiSTRATION (FOIA EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) < <br /> Seri, No. CAL. License No. CAL. L(cz nse Renewal No. <br /> Capacity Gpl., Weights &Measures No <br /> Equipment Parking Address <br /> 2. P, PUMPER YARD <br /> For July 1, June 30„19 <br /> NO.of Vehicles Stored" <br /> Nooi Chemical Toilets Stored <br /> 3. -0 PERCOLATION_ TEST <br /> R.S;or R.C.E. Name R.S. or R.G.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT +J <br /> Job Address/Location <br /> Owner Address <br /> SEPTIC TANK ❑ CESSPOOL XLEACHiNG FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER a- <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served -r <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 /> 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 re tions of the San J Local Heal9h District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 © July 1 &Received By July 31 <br /> BILLING REMITTANCE $ <br /> REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE kkA S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Deliver <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />