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` Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r 'APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA)J1A.7RAQ4Z>LSN S Sr»�,=1,)C - � Address 20• i4so� ! <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers - <br /> .0. Business Telephone No. _ 4"­* rJ'7 _ Emergency Telephone No. _ <br /> Contractor Licence No. ZS'-I S 4 <br /> CApplicants Name (Print) L�/L Title E�"ti`I L-4,&71--n%2 — Date - l ! 1 1 <br /> i. Please check Applicable Category(1-7) and Fill in the Required Information <br />( - 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) U <br /> For July 1, June 30, 19 Disposal Sites <br /> Description (Make/Yr., Color) <br /> a <br /> ,Serial Na. CAL. License No. CAL. License Renewal No. <br /> Capacity _ Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> 4 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> F"t 3. ❑ PERCOLATION TEST IL <br /> R.S. or R.C.E. Name R.S. Or R.C.E. NO. <br /> Test Location Test Date/Time j <br /> 4. SANITATION PERMIT <br /> Job Address/Location1► !1 t-��r r.- �t.Y2 RA`LI- <br /> Owner Address E; " <br /> 11SEPTIC TANK 13CESSPOOL [a--LEACHINGIELD Cr SEEPAGE PIT I-] PACKAGE PLANT <br /> 2ERMANENT ❑ TEMPORARY ❑ NEW B REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> i 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 I <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 k 1 <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 applIcatio. that t work will be done in accordance with San Joaquin County <br /> Ordinances, state law sand reg Ions o e an J qui Lo al Health District. <br /> P <br /> APPLICANT'S SIGNATURE <br /> ,FOR DEPARTMENT USE ONLY J <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 $ REMIT i <br /> BASE - EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED _ AMOUNT <br /> zY FEE ' L� .L ef 4 <br /> LO !€ <br /> - <br /> PRORATIONs- <br /> `.PLUS- <br /> PENALTY <br /> . ti� r <br /> OTHER + p <br /> OTHER - { <br />� ._ 3 c)�_ <br /> l �..._._ <br /> Received by - - Date., - _Receipt No. --� Permit No: ,,,� Iss once a e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:¢ ENVIRONMENTAL HEALTH PERMIT/SERVICES- 1601 E.HAZELTO .,P.O.'Boi 2009 - STOCKTON,CA 95261 <br />