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Applications Will Be Processed When Submitted Properly,Completed. Be Sure To Sign The Application. ' <br /> _ <br /> APPLICATIONw <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatio r by ma¢e to carry, busi es in the juri Ictional area of the San oaquin Loc Health District <br /> rn Business N��{ A) 1 �! jC C� UCS', Address �SC �y` �.I <br /> aOwner—_5 6A 06 e/g Address <br /> aFirm Partners, Addresses and Telephone Numbers <br />{[[ a Business Telephone No. - IL ��3"� E*i1�'� Emergency Telephone No, <br /> I Contractor Licence No. 91 9 6 _ 1 <br /> L Applicants Name (Print) _ Title Date tl`� <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br />! 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) j <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No. CAL. Licz nse Renewal No, <br /> Capacity Gal.,Weights & Measures No. <br /> L Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> I No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> j R.S.or R.C.E. Name R.S. or R.C.E. No. , <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT �l <br /> Job AddressLLacation 7 $19 S. U PUI0.1-j RRA o M A w'rscA <br /> Owner /nAce6o Address <br /> ® SEPTIC TANK. [],CESSPOOL ISI LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑-TEMPORARY- ® NEW ❑ REPAIR^-- 13-OTHER + <br />` 5. ❑ CHEMICAL TOILETS For July 1,-t une 30, 19 �} <br /> Type Construction } Disposal Site /200 CA/ rll vk ,3 70' /.tVrc L ' <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 /> I <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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> d <br /> 1 <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 regulations of the Sanf)oaquin Local Health District. <br /> (/►'+I /C <br /> APPLICANT'S SIGNATURE X <br /> - FOR DEPARTMENT USE ONLY <br /> ■ <br /> Fee Is Due: 0 ANNUALLY El PER UNIT ❑-PER SITE ❑ EACH ❑ January 1 &Received By January 31. ❑ July 1 &Received By Juiy 31 - <br /> REMIT <br /> SASE EXPLANATION SICCING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE_ - REMITTED AMOUNT <br /> FEE �'S sg F `7S <br /> _a <br /> LESS <br /> PRORATION <br /> PLUS + - - <br /> PENALTY S ,j <br /> OTHER <br /> OTHER <br /> �.p I J <br /> Received by Tate L Receipt No Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _ 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 952131 <br />