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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. € l <br /> APPLICATION <br /> - = (For Non-Transferable, Revocable, and Suspendable) I <br /> ENVIRONMENTAL4H.EALTH PERMIT SEPTA.GE <br /> I <br /> LIQUID WASTE i i{ <br /> Application�1�}hereby,ma a to,carry on business in the jurisdictionsl area of the San Joaquin Local Health District { <br /> y Business Name (DBA)—�sC, �, /�iu �. �'!`-�/[,� Address Pe" i t <br /> aOwner , A Address <br /> 0,Firm Partners, Addresses and Telephone Numbers s <br /> aBusiness Telephone No. O Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) L- 9 I Title &ZS Date <br /> VJ <br /> Please check Applicable Category (1-7) and Fill in theRequiredInformation , ,l �} <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. Licc,se Renewal No. ( �j <br /> - <br /> Capacity GaI7Weights-.&_Meas0res-N0: - it <br /> Equipment Parking Address j <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored k <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST I <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. I <br /> Test Location Test-Date/Time I) <br /> 4. 0 SANITATION PERMIT <br /> Job Address/Location I bl <br /> Owner G i� ST�da nss2 c� IP <br /> fiq SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> I <br /> 5. ❑ CHEMICAL TOILETS For July 1; -June 3Q, 19 <br /> Type Construction Disposal Site _ <br /> I <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 :r <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July-1,--June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., -11 More Than 1,000 Sq`Ft._. <br /> � 1 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ` <br /> I hereby certify that I have prepared this application and that the.work wilt-be done in accordance with San Joaquin County I} <br /> ordinances, state laws, and rules and regulations of than Joaquin Loca1 Health District. a <br /> APPLICANT'S SIGNATURE X - <br /> 731 <br /> FOR DEPARTMENT,USE ONLY r <br /> Fee Is Due: © ANNUALLY id PER Al-r 0-14ER SITE ❑ EACH '❑ January 11-Received By January 31 ❑ July 1 &Received By July 31 <br /> ' REMIT <br /> BASE EXPLANATION 'BILLING REMITTANCE $ { <br /> DATE -DATE 'REMITTED gMOUNTDUE CHECKED l AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - I <br /> PLUS f <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Recei by Date iReceipt.No. Permit No Issuance Date Mailed Delivered y <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AYE.,P.O.Box 20119 STOCKTON;CA 952111 <br /> I t� F <br />