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en Submitted Properly Completed. Be SureToSign anewppncanu <br /> Applications Will Be Processed Wh <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) <br /> ENVIRONMENTAL h"EALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Appl icatio r��¢ madde to car b si ss in tl�e jurisdictional area of,the XS o_elqui➢I Health Dist <br /> F Business Name (DBA) <br /> M IC I K'S CIMOC'. �.• I� Address / l3 AveQT <br /> z Owner Address <br /> J Firm Partners, Addresses and Telep a bers <br /> E Business Telephone No. `� Emergency Telephone No. <br /> Contractor Licence No. Date. <br /> L Applicants Name (Print) Title <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 /> CAL. License Na. CAL. Licc7se Renewal No. <br /> Serial No. <br /> Capacity Gal., Weights & Measures No. <br /> t Equipment Parking Address <br /> 1 2. ❑ PUMPER YARD a -' <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored r <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E.No. <br /> R.S. or R.C.E.Name <br /> Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT.4 <br /> Job Address/ collo �6 ��� �.�?T/�Ilz.� <br /> f Owner �' ` C� Address <br /> ' <br /> C1 SEPTIC TANK 11 CESSPOOL LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR . ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 k <br /> Type Construction Disposal Site DA Atm <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> $. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> I Where Certified <br /> f Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> � r <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 /> 'h <br /> { <br /> ate`` 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 regulations of the San Joaquin Local Health District._ <br /> APPLICANT'S SIGNATURE X . <br /> } FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑-PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By.January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> EASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS -4. - <br /> PRORATION <br /> I PLUS.. <br /> PENALTY <br /> OTHER b <br /> OTHER' <br /> elivered <br /> Received by Date Receipt No. <br /> Permit No. Issuance Date Mailed D ',cc <br /> APPLICAjA" -URN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ' X601 E.HAZELTON AVE.,P.D.BOX 2 09. 5TOCKTON,GA i <br />