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Applications Will Be-Processed When Submitted Properly Completed. Be Sure To Sign The Application.. 4 <br /> APPLICATION �- <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> r� 11 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 /> F Business Name (DBA) 5cey <br /> z OwAddress.. �• 13 x I <� I"/bflPsTo C,�J, <br /> Owner <br /> Address <br /> .r <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. sX 3 - Y a,! 9 Emergency Telephone No. <br /> Contractor Licence No. 6 -S 04 <br /> L Applicants Name (Print) Title 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 /> k <br /> Serial No. CAL. License No. CAL. License Renewal No. ` <br /> -_ Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address +=' <br /> 2. ❑ PUMPER YARD r <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored n �! <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> 1 <br /> I R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location <br /> Test Date/Time <br /> 4. ❑ SANITATION PERMIT; <br /> Job Address/Location 3 ? Y8 moo. IUtyip,y 4',Z <br /> a <br /> Owner e&— 4greiee Cia 4 50,ev Address <br /> ® SEPTIC TANK ❑ CESSPOOL 0-LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW O'REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS -:For July 1, -June 30, 19 U I <br /> Type Construction Disposal Site C4 <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., ❑rMore Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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 r es and regulations of the San Joaquin Local Health District. 4 " <br /> APPLICANT'S SIGNATURE <br /> OLD. curn� <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 1i <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT K <br /> DATE DATE REMITTED - AMOUNT DUE CHECKED <br /> AMOUNT <br />' FEE <br /> LESS } <br /> PRORATION ^ ' <br /> PLUS - <br /> i <br /> PENALTY r \� <br /> OTHER { <br /> OTHER r <br /> 3 <br /> Received by ate Receipt No. Penni[No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALLCOPIESTO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES. 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> t �, <br />