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Applications Will Be Ptocessed When Submitted Properly Completed. Be Sur To Sign The Application. , lI <br /> APPLICATION Z J01 <br /> ( Ion-Transterable,Revocable, and Suspendabl( 1 <br /> eNVIRONMENTAL HEALTH PERMIT / SEPTAGE <br /> LIQUID WASTE <br /> Application 15 h rebyfJmade to car on business in the jurisdictional area of the San Joaquin Local Health District <br /> . Business Name (DBA) �'F� Y il�t_0�, Address �O� na✓ � 4V ' /C <br /> iOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> � <br /> Business Telephone-No. CG�hL?"�' 'J ,'/ Emergency Telephone No, <br /> Contractor Licence�No. .,�"'— <br /> Applicants Name (Print) d- 1• ��'��1�� Title .. - -- Date <br /> Please check ApplicAle Category(1-7) and Fill In'the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1I� <br /> For July 1. June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) _ ' <br /> Serial No. CAL. License No. CAL. Liccnse Renewal No. <br /> Capacity Gal.,Weights & Measures.No. <br /> Equipment Parking Address '•' 0U <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 y R.S. or R.C.E. No. <br /> Test Location _ Test Date/Time Q- <br /> 9. ❑ SANITATION PERMITT 7 �t <br /> Job Address/Location �6 / .. w,67,91P C. 11144 rv. <br /> O�wn�' ����S f-• • Address 4� �� ;7- <br /> Id SEPTIC TANK ❑ CESSPOOL Ga'LE�CH(NG FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT _ <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 11-June 30, 19 <br /> Type Construction Oisposal Site �n <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: ❑ Les5 Than 1,000 Sq. Ft., More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 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 of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X QCoO , <br /> FOR DEPARTMENT USE ONLY - <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PI(h SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Recelved By July 31 <br /> BILLING REMITTANCE / $ REMIT <br /> BASE EXPLANATION DATE IJ DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 5 t 5 <br /> LESS <br /> PRORATION <br /> PLUS (,y / -� <br /> PENALTY t. <br /> OTHER <br /> 1 <br /> OTHER <br /> Recelved by Date Receipt No, Permit No. I Suan e O le Mad'e� Delivered ---7 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA ELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />