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k Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> �--1' ENVIRONMENTAL HEALTH PERMIT <br /> SEPTAGE <br /> LIQUID WASTE <br /> r Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> to Business Name (DBA) Address 7i 1!9 L 57` s7aG ,d <br /> aOwner # Address <br /> aFirm Partners, Addresses and Telephone Numbers <br /> I a Business Telephone No. 3 9"7/ Emergency Telephone No. <br /> Contractor Licence No. �S' 3 Off] <br /> L Applicants Name (Print) f LJ 4'5C--b Title 16:5v— Date 'T_ <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> I. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 { Disposal Sites <br /> Description(Make/Yr., Color) _ <br /> i Serial No. I CAL. License No. CAL. Liaise Renewal No. <br /> Capacity GaLdWeights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For J41, 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 Location Test Date/Time <br /> 4. g SANITATION PERMIT <br /> Job Address/Location 45 3 2L-0 4, /lr/E13� i4TJe5� 57aC.�7l77tJ _ <br /> OwnerAddress— E _ <br /> V SEPTIC TANK ❑ CESSPOOL LEACHING FIELD X SEEPAGE PIT ❑ PACKAGE PLANT <br /> I ❑ PERMANENT ❑ TEMPORARY ❑ NEW .REPAIR ❑ OTHER (N <br /> S. ❑ CHEMICAL TOILETS For July 1;=`June 30, 19 <br /> Type Construction ! Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> II 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location Jt <br /> Plant Capacity t 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 application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and rev3ulatio of San Joaquin Local Health Dist _ <br /> APPLICANT'S SIGNATURE X kk&e <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By.January 31 © July 1 &Received By July 31 J <br /> BILLING REMITTANCE $ REMIT <br /> RASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED y j <br /> AMOUNT F!f <br /> 4 <br /> FEE x <br /> �%' <br /> LESS ,j <br /> PRORATION r- 1 <br /> PLUS ! <br /> PENALTY <br /> OTHER <br /> OTHERt� _ I <br /> Received by- Date } Receipt No. Perms No. Issua ce Date.:; M Delivered <br /> APPLICANT RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERM ITISERVICES', 1601 E.HAZELTON AVE.,P. 09 5TOCKTON,CA.95201 <br />