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Applications will tie Processed when submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-TransftrablA,1111164oCNbld,And Suspendable) SFPTAC f: <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the Jurisdictional area of the San Joaquin Local Health District <br /> FBusiness Name (DBA) Address <br /> a Owner______ _ - Address <br /> J Firm Partners, Addresses and Telephone Numbers 0F:Cj iF-t��g jZ �, �V1YTL9Z.� L�j[f�-13cfJr <br /> aBusiness Telephone No. Emergency Telephone No. <br /> J Contractor Licence No. " <br /> Applicants Name (Print) , � ��s! _ TitleDate_ -7 _ <br /> Please check Applicable Category(1-7)and Fill In the Required Information <br /> I. ❑ 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 Gal., Weights & Measures No. <br /> Equipment Parking Address � tt <br /> ❑ PUMPER YARD <br /> F '"``` 2 M6 '6 l! <br /> For July 1, June 30, 19 _ <br /> No. of Vehicles Stored 1.1 g �� �Q,`�s o4j <br /> No. of Ch Tical Toilets Stored �00 <br /> 3. � PERCOLATION TEST U �_ <br /> R.S. or R.C.E. Name �1JP�IJ'Zl�/J R.S. or R.C.E. No. <br /> Test Location WAODD � `P�6AV7 Test Date/Time ywLl <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> 1 <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 /> 7. ❑ 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 prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, �Ies d r ations.pf a San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> Ue� lr.�� \/2- <br /> FOR <br /> lzFOR DEPARfiIIMLPIT USE ONLY,-._ <br /> Fee Is Due: h ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE E REMIT <br /> BASE — �EXPLA ATIO1 DATE DATE EMITTED AMOUNT DUE CHECKED <br /> /� qI J? G �� AMOUNT <br /> FEE 7- <br /> 2-70:U• 7-13 -0 a y� VC/ - � 3 <br /> LESS <br /> PRORATION 9 �� <br /> PLUS <br /> PENALTY /0 2 <br /> OTHER <br /> OTHER ..../ �j <br /> y,dt7 --- <br /> ___4A. <br /> ec 2-by -' <br /> Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAYELTON AVE.,P.O.Box 2oo9 STOCKTON,CA 95201 <br />