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Applications Will be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATIOSk <br /> N <br /> ~� (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE G <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> H Business Name (DBA) A• PA P—A I S/,F 0� ma&A. S' Address 110 B 10sy. <br /> z Owner -. Address <br /> 0- Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. .2 .3 3 <br /> E C Applicants Name (Print)_F4A_2 ;wa-y-Z Title E$r?AffAr-&Pr2 Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> t For July 1, June 30, 19 Disposal Sites' <br /> Description(Make/Yr., Color) �1 <br /> [ Serial No. CAL. License No. CAL. Uccnse Renewal No. <br /> Capacity, Gal.,Weights &Measures No. <br /> 7 <br /> Equilanlent Parking Address' -- <br /> 2. ❑ PUMPER YARD 10 <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 <br /> Test Location ..Test Date/Time_ <br /> 4. 9 SANITATION PERMIT =. J- ' <br /> I Job Address/Location 73'5/7 IV. <br /> Owner -ir . *' -Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL-- - LEACHING FIELD . ❑ SEEPAGE PIT ❑ PACKAGE PLANT , <br /> 1' PERMANENT ❑ TEMPORARY_ ❑ NEW REPAIR OTHER Su�P <br /> 5. ❑ CHEMICAL TOILETS For July,.1, -June 30, 19 <br /> Type Construction 'ill� 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 <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 /> 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 regulations of the an oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X - <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 0 January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE, DATE REMITTED AMOUNT <br /> FEE ! <br /> LESS 4 <br /> PRORATION <br /> PLUS f r <br /> PENALTY t <br /> OTHER <br /> OTHER ; <br /> Received by Date Receipt No. Permit'No. Issuance Data Mailed Delivered �'� <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 99 01 <br />