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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign 1 no AppllcaTlon. <br /> APPLICATION <br /> 'F (Far Non-Transferable,Revocable,and Suspendable) <br /> it <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application Is hereby made�t�o/carry on business in�the jurisdictional area of the San Joaquin local Health District ` <br /> HBusinessName_(DBA)46weL -�� Rite �¢r'ytc��rD'�• - - Address _ � c <br /> AAWle <br /> OwnerJo t Ose elf I% kj J'7 Address X-73—, ! 1� fy_ is/ ►s f <br /> S2T fep <br /> .Firm Partners,Addresses and hone Numbers - <br /> �� <br /> CL <br /> Business Telephone No. ^� Emergency Telephone No. <br /> -J Contractor Licence No. <br /> Applicants Name(Print) )- Title �� 1'<' Date <br /> Please check Applicable Category(1-7)and t=ill 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„Collor) <br /> Serial No. • CAL. License No. CAL, Ll=nse Renewal No. <br /> Capacity_ yr Gal.,Weights&Measures No. <br /> Equipment Parking Address <br /> +.. <br /> 7. 13 PUMPER YARD - t <br /> For July 1, June 30, 19 1! <br /> No.of Vehicles Stored <br /> No. of Chemical Toilets Stored ' <br /> 3. ❑ PERCOLATION TEST n• <br /> R.S.or R.C.E.Name R.S.or R.C.E.No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT ,r <br /> Job Ad Location <br /> Owner [J Address J-2001 RT N <br /> SEPTIC TANK ❑ CESSPM A LEACHING FIELD SEEPAGE PIT 0 PACKAGE PLANT Q <br /> ❑ PERMANENT ❑ TEMPORARY 9 NEW # ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30. 19 <br /> Type Construction _ --r17isposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> S. © 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. Fl., ❑ More Than 1,000 Sq.Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I <br /> 1 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, n rules end r uiatio soft San Joaquin Local Health district. <br /> :APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:© ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 6 Received By January 31 ❑ July 1 A Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHE1i <br /> �ss7ji9� <br /> Received by Date Receipt No. Penmit No, 118suance Dale Mailed Delivered <br /> •. APPLICANT—RETURN ALL COPIES TO: ENVIRONMEUTAL HEALTH PERMIT/SERVICES 16M F.14AZELTON AVE,P.O.Boa 2005 STOCKTON.CA 4,6201 <br /> ��•�9•g0 �?''Q,re,.�, i l <br /> i <br /> I <br />