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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SjJ Tf1e"pNCaNW1. `'� 7 <br /> -11 .APPLICATION /.. J7 f�JJ <br /> IF r0-Transferable, Revocable, and Suspendabie JOAQUIN LOC FpTAGE i I <br /> ENVIRONMENTAL HEALTH PERMIT HEALTH DISTRICT p <br /> LIQUID WASTE V <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquincal Health District _S <br /> wBusiness Name (DBA) /00h C6S� �¢S'S1J Address /9F� �T Gy <br /> i Owner 17n Jh CAS ff- Address ' Al.' <br /> Firm Partners,Addresses ands T'elltep-hone Numbefst <br /> 'n Business Telephone No. S'AZz ;Emergency Telephone No, <br /> Contractor Licence No. <br /> Applicants Name (Print) _ ` Title 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 /> Description(Make/Yr.,Color) C <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gat.,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 • L j <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. ❑ SANITATION PERMIT "Y <br /> Job Address/Location 4QT—.��T Id� =3- -� `��n�/� 4� <br /> Owner tOn,q C6C 6- Address <br /> R SEPTIC TANK ❑ CESSPOOL LEACHING FIELD Q SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY O NEW - ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 1.30, 19 <br /> a � <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locatiort(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 1,00 Sq. Ft. <br /> ❑_DRY CLEANING,Chemicals Used/Amount/Mo. <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 ruIIand_r eg�ulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X - <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑PER UNIT ❑ PER SITE ❑ EACH ❑ January 18 Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> 4-_ AMOUNT <br /> FEE /J` D <br /> LESS <br /> PRORATION <br /> PLUS v <br /> PENALTY <br /> OTHER <br /> OTHER <br /> � O <br /> (Jt bZ ll�a7/-27 1,56 -3- 633-1 I�r �4 <br /> Received Dy Dat Receipt No. Permit No. Iss e ce bare Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Soa 2099 STOCKTON.CA 95201 <br />