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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) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAG <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of th an Joaquin Local Health District <br /> �n Business Name (DBA),�� � 1�5� /fir, 'rQJG • Address�� k «S6 :� 9�Z� <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 0 7 _.__._ Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) :5_7 `. S TitleDate s6! d <br /> Please check Applicable Category (1-7)and Fill in the Required Information W <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 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 Loc Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location Z���"S L.LJX}c�f!JtJTr rd p <br /> Owner &AeS. 4. Address C4 <br /> ❑ SEPTIC TANK ❑ CESSPOOL 2'LEACHING FIELD C-SEEPAGE PIT ❑ PACKAGE PLANT 'Q <br /> 2-'PERMANENT ❑ TEMPORARY ❑ NEW _'REPAIR ❑ OTHER N <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 /> 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 ha a prepared this application and Pat the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, d rules and ulations the S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION DATE DATE RE41 TED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE T5.o� •VVC.J( <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY / <br /> OTHER Y <br /> OTHER <br /> 4 - 60 <br /> Received by Date Receipt Np. - Permit No ssuance Date Mailed Pd <br /> PLICANT—RETURN ALLCOPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />