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U 4 Applicatlon IYJi Be Processed When Submitted Properly Completed. Be Sure to Sign The Application. 1 <br /> r\.�EP 7 1979 APPLICATION . <br /> IF on-Transferable,Revocable,and Suspendable, <br /> ENVIRONMENTALSEPTAGE <br /> HEALTH PERMIT <br /> SAN JOAQUIN LOCAL <br /> HE%TLIQUIDWASTE((]]( , <br /> IcSTRICT . <br /> Is hereby made to carry on busines@ in the jurisdictional area of the San Joaquin Local Health District <br /> q Business Name (DBA) . . . Dn h QS�'F Address. 9E G� C�C <br /> Owner .DO/� �O$ Address —( ____W C1F17I16' II 'Q r^ <br /> Firm Partners, Addresses and Telephone Numbersy o <br /> c. Business Telephone No. ,Emergency Telephone No. <br /> Contractor Licence No: - S_ <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1.7)and FII( in the Required Information <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 L� <br /> No. of Chemical Toilets Stored _ C <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.'qSANITATION PERMIT, <br /> Job Address/Loca�ti° Y-(„� YV i <br /> q-77 Owner <br /> SEPTIC TANK ❑ CESSPOOL 19 LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT >f{' <br /> ❑ PERMANENT Q TEMPORARY NEW- ❑ REPAIR Q OTHER <br /> S. .0 CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site ' <br /> No. of Units Equipitient Storage/ClBaning Location(s) T <br /> 6. 11 PACKAGE TREATMENT PLANT For July 1,-June 30;19 - I' <br /> Operator Name - Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served C <br /> 7. ❑ LAUNDRY For July 1,-June.30, 19 - 3 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Fl. <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,an les and regulations of the San oaquin 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 6 Received By January 31 ❑ July 1 It Received By July 31 <br /> REMIT <br /> BASEBILLING <br /> Ej(PLANATION DATE RE DATE REMITTED <br /> REM TTED AMOUNT DUE CHECKED <br /> ((�� AMOUNT <br /> FEE Y'S. O - 4c 4S <br /> LESS ' <br /> 1 PRORATION " <br /> PLUS q <br /> PENALTY 1 <br /> r OTHER <br /> OTHER <br /> FS L <br /> 79 S 9/18179 <br /> Received by Date Receipt No, Permd No. Issuance Dat Mailed Deb.ered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bol 2D09 STOCKTON.CA 95"1 <br />