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Applications Will Be Processed When Submitted Properly Completed. BeSureToStgn�nppn Fvnb <br /> APPLICATION _ , <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAbE i 'k <br /> ENVIRONMENTAL-HEALTH PERMIT • '*, 4 � .' f <br /> LIQUID WASTE <br /> 3 <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin..Local Health Disttrrrl•ct <br /> N Business Name (DBA) ,Address . <br /> a <br /> • . _ Address <br /> Owner: - _ - <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No. <br /> } <br /> Contractor Licence No. T - <br /> a - � .. � � Date_... <br /> L Applicants Name (Print) r } <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, i9 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> Serial No. <br /> `KCAL. License No.' - CAL:License"RenevtiaFNo. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. PUMPER YARD t <br /> For-July 1, June 30, 19 L � <br /> No.,Of Vehicles Stored <br /> No Of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R-9.'or R.C.E. Name i R.S. or R.C:E.No. <br /> Tat Loc tion Test Date/lime �,� � ' s <br /> 4. 0 SANITATION PERMIT e'w. <br /> kb'Address/Location <br /> Owrier_ 4'+[ A - Address F <br /> ❑ SEPTIC TANK ❑;CESSPOOL O LEACHING-FIELD IJ SEEPAGE PIT ❑ PACKAGE PLANT' <br /> PERMANENT -r❑ TEMPORARY 'C3 NEW �» ( EPAIR ' ❑`OT1lER - ` <br /> 5. ❑ CHEMICAL TOILETS For.J ly i, -June 30, 19 1, .,, �� .�-.:•-- --�..- ) <br /> Type Construction ms`s ry _ Disposal Site r_ <br /> No. of Units <tot, Equipment Slorage%Cleaning'Location(s) <br /> • 's ) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> $ « 1•.. r Where Carrtifled ' <br /> Operator Name <br /> Plant Location <br /> Nd. Units <br /> Plant Capacity Served <br /> I `S <br /> 7- ❑ LAUNDRY For July 1,-June 30, 19 - <br /> 'SIZE: C3Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. + <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Cx <br /> I ,hereby certify that I have prepared this application d that a ork will be done In accordance wh 5an Joaquin Coun4y_.t <br /> s ordinances, state laws, d r es and reg tions of an aq n Local Health Distract ,.; x ». •� „_ • # a <br /> A <br /> l APPLICANT'S SIGNATURE X <br /> S r <br /> f <br /> F = FOR DEPARTMENT_USE'.ONLY <br /> _ y <br /> } _ <br /> Fee Is Due: ❑_ ANNUALLY ❑_PER UNIT, ❑ PER SITE ❑ EACH ❑ January 1 &Received By JSntiary 31,,,n .,❑ July 1 8.Received By iy. �I <br /> BASE EXPLANATION ,BILLING REMITTANCE AMOUNT DUE E�� <br /> _ DATE DATE <br /> REMITTED <br /> \NT <br /> FEE �S <br /> LESS t <br /> PRORATION _ <br /> _ � s <br /> PLUS € a <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Date ReceiptjNo- a Permit No. Issuance D e Mailed Delivered ti <br /> Received;by _ c <br /> ce 1691 E.HAZELTON E.,P.O.Boa 2099 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES,TO:''•"ENVIRONMENTAL HCALTH PERMITISERVICES <br />