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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> m Business Name (DBA) w8ba, LIJ ..1{ E �Sy (jy,)C . Address 'LtU Pl. HUNT-FF. STOC��UtJ <br /> a Owner G ChAI NCE Wffl�dci_ Address <br /> Firm Partners, Addresses and Telephone.Numbers <br /> 'n Business Telephone No. ��4 —4•-�-3Z- Emergency Telephone No. <br /> a <br /> Contractor Licence No. _ <br /> Applicants Name (Print) CHNI�<t. W — Title PRES• 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 Stor <br /> 3. )I PERCOLATION TES e <br /> R.S. or R.C.E. Name C• B A N CE WON& R.S.Or R.C.E.No. C' E . I T 11- <br /> Test Location I'Imo_—YZ, • ET RQ G-17, Test Date/Time <br /> 4. ❑ SANITATION PERMIT Pt�t�s SU5C,kUISiQW 5✓ -79 _I0 'A fFrERSgI�K'•(1' <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/Amount/Mo. <br /> I hereby certify that I have prepared this a pit do hat the wo will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules and regul i s t e re Joaquin o al alth District. <br /> APPLICANT'S SIGNATURE X 'FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January/ &Received By January 31 ❑ July 1 6 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE <br /> EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> � )/1 AMOUNT <br /> FEE UO L—1 'X z <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by, Date Receipt No. Permit No. Issuance ata Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />