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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Won-T.ailsferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> •� "'r' LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ,F Business Name (DBA) WCIJG+ F—WaINF—eKsIIJC. Address x..10 N, 14UNrF—P-- , STOCr--,ZON <br /> a Owner C. G6kA NCE VJ ON G• Address <br /> Firm Partners, Addresses and Tel umbers <br /> ephon``e__N <br /> i Business Telephone No. z T"A�'6SZ- Emergency Telephone No. <br /> a <br /> � Contractor Licence No. <br /> L Applicants Name (Print) C. Gkt AN CE P10NG- Title PK+E S. 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) <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 Store <br /> 3. �a PERCOLATION TEST oe _ /� <br /> R.S. or R,C.E. Name G.W-6�WLC-IF- W o N G- R.S.or R.C.E.No. 1•-•C.E• �443 <br /> Test Location Fluff SLb, �`r 3 RDS ST- Test Date/Time <br /> 4. ❑ SANITATION PERMIT ° (�ETFi�S� SUbIXU6S10P) 5 `—r4"tC U PETERSBUf->& " <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ 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/AmounVMo. <br /> I hereby certify that I have prepared this <br /> agplti hatthe o a done in accordance with San Joaquin County <br /> ordinances, state laws, and rulesand regul a Joaquin o at alth District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNTDUE CHECKED <br /> AMOUNT <br /> FEE bO <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER / <br /> OTHER <br /> Received by D to Receipt No. Permit No. Issuance bare Mailed Delivered <br /> APPLICA T—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boy 2009 STOCKTON,CA 95201 <br />