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-••- •••• >+�.. TV flute auvmnasa rropeny tromplelsa.Be Sure To Sign The Application. <br /> APPLICATION <br /> K' (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is h reby made to carry on b siness in the jurisdictional area of the San Joaquin Local Health District <br /> aBusiness Name (DBA)_- 7 � - Address <br /> aOwner G Address _ <br /> J.Firm Partners. Addresses and Telephone Numbers <br /> ii Business Telephone No. _ Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) �y2, ,�c/L G mac'-_ Title ! - Date <br /> Please check Applicable Category(1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) !C}� <br /> For July 1, - June 30, 19 Disposal Sites W <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. .------ CAL. Liccnse Renewal No. <br /> CapacityGal.,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' - - - - <br /> R.S. or R.C.E. Name _ _ R.S.or R.C.E.No. <br /> Test Location Tesi DatelTime _ <br /> 4. •❑ SANITATION PERMIT �`~`' .� ( t -� ► <br /> Job Address/Location 4G7- -'�' ` 5- _I S -`­0fi>J �-�i <br /> Ownpx Address— sli =�� '-�/=��- e� �V, <br /> [�/SEPTIC TANK CESSPOOL EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT _ <br /> -- -. _ <br /> ❑ PERMANENT ❑ TEMPORARY ❑lNEVd� r ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For-Jufy 1,-June 30J19 1 <br /> Type Construction • is Disposal Site <br /> No. of Units.2' Equipment"Storage/Cleaning Location(s)_ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July, - June 30, 19 ' <br /> Operator Name Where Certified <br /> .Plant Location yr` <br /> Plant Capacity—__. r _ No. Units Served <br /> 7. Q.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/Arrtflunt?Mo.� <br /> f• <br /> I 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 re I tions of the San Joaquin Local Health District. <br /> r 110, <br /> APPLICANT'S SIGNATURE X s_ r <br /> l <br /> a . = <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE r,❑ EACH - <br /> __- _ •❑ January 1 8 Received By January 31 ❑ July 1 8 necelvetl By July 31 <br /> BASE a111.ING MITIANCE REMIT <br /> a <br /> EXPLANATION <br /> DATE PATE REMITTED AMOUNT OUE CHECKED <br /> _ : AMOUNT <br /> FEE <br /> LESS — <br /> PRORATION <br /> Pois <br /> PENALTY - - .� IV _ - _ - •_ <br /> O1HER <br /> OTHER - - Id - ! - <br /> 9 � <br /> _ a �s ue <br /> Received by Date HeceIP1 NO <br /> Permit No -T�. •) sue Date Malted pelivereal JG . <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - •,. 1601 E.HAZELTON AVE..P.O.Box 1009 STOCKTON,CA 962011 <br /> I <br />