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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTATE fp <br /> ENVIRONMENTAL HEALTH PERMIT 0 <br /> LIQUID WASTE r <br /> A licationn'''h ad to carr eb}�sT�wess in the'urisdictional area of the Sa a Local H alth District <br /> o Business Name (DB (' ��✓r _ 1 .,/ Ad esc� 6�/f, <br /> Owner Address' '7C//'y . V- Qiw-,w <br /> u Firm Partners,Addresses and Telephone Numbers c £ 0LU - - <br /> iBusiness Telephone No. � 3Y33 Emergency Telephone No. Ste- e <br /> Contractor Licence No. 4o 7' 2 <br /> Applicants Name (Print) IC.z E Title X40 � 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. License Renewal No. <br /> Capacity Gel.,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. ❑ PERCOLATION TEST Q <br /> R.S. or R.C.E.Name [e- � �`�" R.S.or R.C.E.No. <br /> Test Location Test Date/Time f <br /> 4. ❑ SANITATION PERMIT t <br /> Job Addressncaion !S' 'tp <br /> Owner r- .o Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL <br /> C3 LEACHING FIELD ❑ SEEPAGE PIT 11ACKAGE PLANT <br /> ❑ PERMANENT 13fi TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction 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 /> T. ❑ 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 /> I hereby certify that I have prep is applic d t the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, and r d reg ation Sa Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE A <br /> i <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> I"1s Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH. ❑ January 1 a Received By January 31 ❑ July 1 a Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE 'REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE "eY L5 <br /> LESS \�1` <br /> .. ... <br /> PRORATION \ !' ' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date ReCaiIN No. - - Permit No. Q Issuance Dele Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL REALTH PERMIT/SERVICES tact f.NAZELTON AVE.,P.O.Boa 2009 STOCKTON.CA%tat <br />