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Applications Will Be Processed When Submitted Properly Completed. Be Sure To.Sign The Application. J 1 <br /> APPLICATION 161 /g <br /> ( Ion-Transferable, Revocable,and Suspendabl <br /> ENVIRONMENTAL HEALTH PERMIT / SEPTAGE <br /> LIQUID WASTE <br /> Application is heAr Bby ade to carryon business In the jurisdictional area nt��h�ar San Joaquin Local Health District <br /> Business Name (DBA) �r9�' z4 6'e AddreSY '�'�� ,�`SGS -- . .— <br /> `z Owner ,./ , ri�LL,�_—lP� Address — -- <br /> Firm Partners, Addresses and Telephone Numbers - — <br /> a Business Telephone No. r Empr"gency Telephone No. . .o.�- <br /> . <br /> Contractor Licence <br /> L Applicants Name (Print _�..,�./-7z G Title —Qw N�2 Date <br /> � <br /> Please check Applicable Category(1-7).and Fill In the Required Information G� <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. Liccise 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. V <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT, <br /> Job Address/Location � •T ��—� <br /> iOwn Address � T`r'r�5 / G <br /> PTIC TANK ❑ CESSPOOL LEACHING FIELD 0 SEEPAGE PIT ❑ PACKAGE PLANT ' <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5" .0 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., 0 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/AmounVMo. <br /> ti <br /> I hereby certit that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, and rules and regulati s cf,the.SS/ann J�quin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE • ❑ EACH ❑ January 1 A RecelYed By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION OAT GATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> l — <br /> FEE .415 b <br /> LESS f <br /> PRORATION - <br /> PLUS <br /> PENALTY _ <br /> OTHER \ <br /> OTHER V) <br /> /O <br /> 7S Zan <br /> Received by Date - Rmeml No. Permit No. Dat Mailed Debver <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE.,P.O.stir 2009 STOCKTON.CA 95201 <br />