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� gppl atiolis Will Be Processed When Submitted Properly Completed. BeSureTo signl-a,r„r,. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPrtAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Application is her bytnade to carry on business in the jurisdictional area of the San Jaag� uin Local Health District pti <br /> � �.� ::�� Address � �•! � <br /> Business Name (DBA) l <br /> Address <br /> a Owner <br /> u Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> aBusiness Telephone No. <br /> Contractor Licence No. f .� Title a'� J Date <br /> L Applicants Name (Print) n t <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 /> ,r,_.,..� _s.r�,l. , - -+� ----- CAL"License Renewal No. + <br /> Serial No. . CAL. t_iCense No. ; <br /> # ` Gal_Weights & Measures No. i <br /> Capacity - M <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. ❑ PSERCOLATION TEST 4 <br /> ti fR:S.or R.C.E. No. f <br /> R.S.or R.C.E.':Name <br /> Test Date/Time <br /> Test Location. t <br /> 4. ❑ SANITATaON-PERMIT.� 50 � �q <br /> Job Rddress/Location 1 <br /> { -' ► i f! Address <br /> t Ow �,� ❑,PACKAGE PLANT q <br /> t. 9 SEPTIC TANK ❑TGESSPOOL-- ��ACHING FIELD 2-SEEPAGE PIT <br /> ` ❑ OTHER 4 <br /> f 13 PER MANENT ❑ -TEMPORARY ❑ NEW EPAIR <br /> k 5. ❑ CHEMICAL TOILETS For-July:-June 30, 19 ; <br /> ` y-40kt-­Disposal Site <br /> Type Construction ; I <br /> s i s+w Equipment Storage/Cleaning Location(s) <br /> No. of Units = ._ =. -- -_ <br /> g. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified ' <br /> • �� -- <br /> Operator Name-- + x- <br /> t <br /> Plant Location <br /> No. Units Served E ` # <br /> Plant Capaoity <br /> ' June 30, 19 <br /> 7. ❑ L+AUNDRY For July 1,t- <br /> Ft <br /> S <br /> ❑ More Than 1,000 q. . + t <br /> SIZE: j[3 Less Than 1,000 Sq• Ft., <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo.. - F <br /> e ` <br /> t <br /> i. <br /> Joaquin;County <br /> 4 t{ <br /> �. <br /> - i hereby certify thathave prepared this application and that`the wok will be done in accordance with San <br /> ordinances, state lawns" and rules and gulations of the.S 2,n Joaquin Local Health District. <br /> 1APPLICANT'S SIGNATURE X_. -° • .,- <br /> § FOR DEPARTMENT USE ONLY i <br /> s ,.. <br /> ? ❑ Januar 1 8 Received BY January 31 ❑ July 1 &Received By JuVy 31 <br /> f Fee IS Due: ❑ ANNUALLYj ❑ PER UNIT ❑ PER SITE © EACH - y ".j REMIT 4 <br /> BILLING REMITTANCE "1'- $ AMOUNT DUE CHECKED <br /> a.. BASE EXPLANATION DATE DATE -,-REMITTED <br /> AMOUNT <br /> FEE <br /> L <br /> T <br /> PRORAION+ <br /> � r <br /> - _ r1 <br /> f PLUS <br /> I tRENALTY <br /> ..—OTHER' _ <br /> OTHER <br /> i Date Receipt No.. ;;Permit Nu. Ins anc Date Mailed Delivered <br /> Received by - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> K <br /> APPLICANT—RETURN ALL COPIES TO ENYkRONMENTAL HEALTH PERMIT/SERVICES ' <br />