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Applications Will Be Processed When Submitted Properly Completed. Be SureTo Sign ineAppiminion. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) j <br /> SI=PTAGE <br /> = ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> y Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) �J.>I.Tl� 5a ley Address �' I�aX OC�&STo C,4. <br /> z Owner Ae-1- T�7air., Address -::5,4 9d' <br /> < r <br /> 2 Firm Partners, Addresses and Telephone Numbers <br /> {r a Business Telephone No. S T -yam Emergency Telephone No. <br /> a <br /> �Contractor Licence No, <br /> L Applicants Name (Print) Title 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. Liccnse 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. 1:1 PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> I Test Location Test Date/Time <br /> 4. 0 SANITATION PERMIT # 7� r Cwt <br /> Job Address/location .A / 9, -" ���1`��5�~ )�y,;F <br /> Owner 5e U� ,- �aXei`a�fl fY Address -gA9^�p As -A&evQr <br /> 191 SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT C/� <br /> I ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR OTHERi r�7 <br /> 5. ❑ CHEMICAL TOILETS For July f1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 % <br /> Where Certified <br /> Operator Name <br /> Piant Location <br /> ? No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., {1 ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> P <br /> I hereby certify that I have prepared,this application and that the work will be done in accordance with San Joaquin County q <br /> ordinances, state laws, and rulesApd regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> . t <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 11ANNUALLY ❑PER UNIT ❑ PER SITE El EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivetlBy July 37 <br /> JREMIT <br /> I -r �ILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT <br /> C <br /> FEE K <br /> 0-4,S <br /> 9 <br /> LESS #i <br /> PRORATION } <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER iI <br /> /7) l d <br /> Received by D to 1 Receipt No. Permit No. Issuan at Mailed Delivered is <br /> I. APPLICANT—RETURN ALL COPIES.TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES 4601 E.HAZEL YE.,P.O.80■2009 STOCKTON,CA 95201 <br />