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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SE;PTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Locai Health District <br /> rn Business Name (DBA) A 5 ctJ Address - -C c 0?AP&�E i T��✓ --- <br /> aOwner. F c..D V.7> (,,,•7 rs 0 F_�) _-_ Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> 1a. Business Telephone No. ��� �`�9-7 Emergency Telephone No. <br /> Contractor Licence No. 3 <br /> (Applicants Name (Print) FLS YD W,2 e p Title ©to ri 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 /> C Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., 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 Test Date/Time <br /> 4. 0 SANITATION PERMIT <br /> Job Address/Location I GO Jll. WA L L P_t]_ L/.I1s--4/_. <br /> Owner -V&ZFA1 rLdNA9,--eci 1,&J/ Address S4,"Z <br /> ❑ SEPTIC TANK ❑ CESSPOOL .k LEACHING FIELD 0 SEEPAGE PIT ❑ PACKAGE PLANT � <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 4�REPAIR ❑ OTHER O <br /> 5. ❑ 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 /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> r ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> f4 <br /> i <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 regulations a an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DAMOUNT DUE CHECKED <br /> ATE DATE REWTTED <br /> AMOUNT <br /> FEE 4,S <br /> 4 LESS 3 <br /> •PRORATION <br /> PLUS <br /> PENALTY )� ` <br /> i <br /> OTHER <br /> OTHER , - <br /> t <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> f <br />