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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. r '� <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) . <br /> ENVIRONMENTAL-LHEAL--T-HTPEiRMiT SEPTAGE <br /> �C LIQUID WASTE <br /> Application hereby made to carryon usiness in the jii'r. dicfipnal area of the San Joaquin Local Health District <br /> W Business Name BA} - �— ��? _ Address ?e '?477 _ <br /> aOwner Address. # <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. (y tA.rz Q S Emergency Telephone No. . _ 0) <br /> a Contractor Licence No. 2 6 1 <br /> Applicants Name (Print), Title Date --2-0_4� f"` <br /> Please check Applicable Category (1-7) and Fill in the Required Yntormation y' <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) (v�' <br /> [ For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccnse 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 /> I Test Location Test Date/Time <br /> 4. 9 SANITATION PERMIT N <br /> I Job Address/L cation _ 3 7a- I <br /> I Owner. zqjA dress <br /> ❑ SEPTIC TANK ❑ CESSPOOL U MLEACHING FIELD ,1E PAGE PIT ❑ PACKAGE PLANT <br /> i <br /> C1 PERMANENT ❑ TEMPORARY C1 NEW L EPAIR ❑ OTHER <br /> f 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. R 7 <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 iv%accordance with San Joaquin County <br /> ordinances, state laws, and rules and lations of the S Jo uin Local Health Dis int. <br /> APPLICANT'S SIGNATURE Xsore <br /> r , <br /> FOR DEPARTMENTUSE Y <br /> f Fee IS Due: ❑ ANNUALLY <br /> El UNIT ❑ PER SITE ❑ EACH J ary 1 &Received By January 31 ElJu3y 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING ANCE $ AMOUNT DUE CHECKED <br /> DATE ATE REMITTED AMOUNT <br /> FEE 4 <br /> LESS <br /> ` PRORATION <br /> PLUS <br /> PENALTY <br /> I OTHER <br /> OTHER <br /> Received by -Date Receipt No- - - Permit No. - Issuance Date -�- Mailed Delivered - - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />