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r , Applications Witl Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> APPLICATION _J <br /> (For Non-Transferable, Revocable, and Suspendable) S) ,i <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE r ! <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District C. <br /> h Business Name (DBA) F lC 5 J�6, Z� Address f �f [L/ iJ.�S'c /�J <br /> OwnerA, j?' %67- Address �r,,.�-A=te � � ��f� (inn �:rs�'�'x �� 4 <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. /` �T Emergency Telephone No. <br /> Contractor Licence No. _ <br /> Applicants Name(Print) �,�: + 1� �+ c ri;.1 Title e-9 w OilI T�.= Date <br /> Please check Applicable Category (1-7)and Fiil in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br />'k Description(Make/Yr., Color) TNI <br /> Serial No. CAL. License No. _ CAL. License Renewal No. r <br /> Capacity Gat., Weights & Measures No. <br /> Equipment_Parking-Address- -f <br /> 2. ❑ PUMPER YARD <br /> For Juiy 11._­ June 30719" <br /> No.-of Vehicles Stored i <br /> .No. of Chemical Toilets Stored <br />` 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name :, 'WS.or R.C.E. Nwc Y <br /> Test Location - ` Test Date/Time { <br /> 4. J. ` <br /> Job❑AddrressT` TcIONo PERM�ITI 10 e <br /> Owner, Address <br /> IBSEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT f k <br />' ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction' � '_ ``�--"r � Disposal Sitex=� <br /> < -- „ <br /> No. of Units i '-Equipment Storage/Cleaning Location(s) x <br /> 6. ❑ PACKAGE TREATMENT,PLANT, For July 1, -June 30, 19 <br /> Operator Name Where Certified A ` <br /> Plant Location <br /> Plant Capacity m`="4 40 _Nb Unit&Served 4 <br /> 7. ❑ 'LAUNDRY For July 1, -June 30, 19 n , may P <br /> SIZE, ❑ Less Than 1,000 Sq. Ft., -11 More Than 1,000 Sq. Ftp <br /> ❑ DRY-CLEANING,-Chemicals Used/Amount/Mo. <br /> - <br /> rr <br /> ' <br /> I hereby certify that I have prepared t Is oplic tion and that the work will be done in accordance4ith San'Joaquin:County�" <br /> ordinances, state laws, an4ru s arr reI u Ions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X - <br /> AL <br /> € FOR DEPARTM6W USES ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE EACH ❑ January 1 &Received By January 31. 0 July 1k&Received Bj�July 31 <br /> 61LL REMITTANCE y .;:9 OL REMIT <br /> " BASE EXPLANATION x AMOUNT>7UE CHECKED <br /> DATE REMITTED # :.r� - <br /> - ti PiMOIJNT <br /> FCE-- <br /> r LESS <br /> PRORATION _ <br /> i <br /> .�_ <br /> F PLUS <br /> + <br /> PENALTY' <br /> ,OTHER <br /> 6TH ER <br /> �..:.�, <br /> Recewed by DateReceipt No. Permit No. Issuance Date Mailed Delivered <br /> - -APPLICANT—RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />