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` Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION 4 <br /> (For Non-Transferable,Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPfAGE <br /> LIQUID WASTE <br /> 2; <br /> Applications eb made to carryon business in the jurisdictional area of th San J aquin Local Health District <br /> F Business Name (DBA) D ��� aox3 ,�+VG Address <br /> � X ! SO sTKN �lSL�' <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephoned Numbers <br /> i a Business Telephone No. �i — % z Emergency Telephone No. <br /> Contractor Licence No. `�. 7, <br /> a �' L Title T Date —3- 91d <br /> L Applicants Name (Print) <br /> Please check Applicable Category (1-7) Ad 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 Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name ' R.S. or R.C.E. No. <br /> Test Lon Test Date/Time <br /> 4. L`J SANITATION PERMIT r <br /> Job Addr ss/Location -q� <br /> I O�wnnee 19f 4u1%,s Address Z <br /> s IS SEPTIC TANK ❑ CESSPOOL I O LEACHING FIELD SEEPAGE PIT y 1:1 PACKAGE PLANT O <br /> 0 ERMANENT ❑ TEMPORARY `. 9<EW ❑ 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 `s <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 /> { <br /> I hereby certify that I h e prepared this application and that the work will be done in accordance with San Joaquin County <br /> r ordinances, state laws, d ules a regulat' ns of arq.Joaquin Local Health District. <br /> ' APPLICANT'S SIGNATURE X i <br /> s2 <br /> disit D � � <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY PER UNIT 11 PEI'SITE C1 EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 37 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE l QO <br /> LESS �l G <br /> PRORATION <br /> PLUS 11 <br /> PENALTY <br /> OTHER <br /> OTHER T <br /> Received by Dater` Receipt No.' Permit No. �.' issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:'' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.FIAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 952DI <br />