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^VVIV.auv13a mes or rra4eyaea wrien auanNtzea rropeny L:ompteted. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) ! <br /> ENVIRONMENTAL HEALTH PERMIT f SEPTAGE <br /> it LIQUID WASTE <br /> I. <br /> Application is her by ade to carry on business in the jurisdictional area San Joaquin Local Health District <br /> Business Name (DBA)��� 1=tr,� �� Add��` <br /> Owner d . / . isrGLc=/Q Address <br /> 3 Firm Partners,Addresses and Telephone Numbers r _ <br /> iBusiness Telephone No. - ; Emergency Telephone No. .c <br /> Contractor Licence No. <br /> Applicants Name(Print) G Title ®�ivy Date <br /> Please cheek Applicable Category(1-7)and FIII In the Required Information UJ . <br /> 1. ❑ PUMPER VEHICLE PERMIT;REGISTRATION (FOR EACH VEHICLE) W <br /> For July 1, -_ June 30, 19 ' Disposal Sites <br /> Description(Make/Yr., Color)- _ <br /> Serial No. —CAL. License No. _ CAL. Liccnse Renewal <br /> Capacity Gal..Weights&Measures No, <br /> Equipment Parking Address <br /> 2, ❑ PUMPER YARD <br /> For July 1, June 30, 19 4 <br /> No.of Vbhicles Stored <br /> No.of Chemical Toilets Stored I Lter,-- --�- �--- •� __ <br /> 3. ❑ PERCOLATION TEST �. <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 <br /> i <br /> _Job Address;LocationERf5,7- BEA L' �F/�j - <br /> _ Adtires3'_ �� <br /> Ul-fEPTIC TANK 0 CESSPOOL`~ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ �P-E1PERMANENT' C1TEMPORARY ElNEW 11 REPAIR 13OTtAI R .a.w•� <br /> 5:_L-I_CHEMICALZO[LETS `For'July'1, -JUKe 30'19 -- "- <br /> Type Construction Disposal Site <br /> No. of Units - IT. 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 r <br /> SIZE-:, ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft <br /> r <br /> r❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I hereby certify that'l have prepared this that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,and rules and regulatl 0s of-We San J quln Local Health Distric'- <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITF ❑ EACH ❑ January 1 a Receivea By January 31 ❑ July 1 8 Received By July 31 <br /> REM11 <br /> Eti <br /> RAST �) EXFIANATIUN BILLING • RMITTANCE DAT DAT_F _ - RFMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE y� I <br /> LESS Ij <br /> ~ - <br /> PRORATION PLUS <br /> PENALTY <br /> - <br /> _ <br /> OTHER - <br /> 75 / �/ el <br /> Received by Date . Receipt Nn Permrt No. uanc Dated Delivered <br /> --- APPLICANT—RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />