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a Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATI-QNB <br /> (For Non-Transferablew Re=Voc.1ble tan S endable) <br /> ENVIRO.NFANTAL, 4AT H MIT SEPTAGL <br /> cti1. { 14 14 ` <br /> Sb T.�t cc�E , ' <br /> V�' _ ,' IQ1SIfJ WASTE 069 <br /> Appl icatio I ereby made t c n b� [�t_D, s`'in the jurrisc a;ior��r a of th San Joaqui Local H ith District <br /> r Business Name (DBA) � � �'�! + 6 L, j, Address I �0- 9SI&I <br /> z Owner Address <br /> S Firm Partners, Addresses and Te hone N tubers E{ <br /> a "Telephone No. r ` Emergency Telephone No. <br /> Contractor Licence No. Y� <br /> Applicants Name (Print) Title Date r <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 /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. <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. ❑ PERCOLATION TEST ^ ! <br /> R.S.or R.C.E. Name +F R.S.,or R.C.E. No. <br /> Test L cation �Test•Date%Time <br /> 4. SANITATION PERMIT <br /> Job Add r s/Location Ze4n4 <br /> O ner Address ` 1 S o -• ' <br /> SEPTIC TANK ❑ CESSPOOL X( LEACHING FIELD 11 SEEPAGE PIT PACK AGE PLANT { it <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTIQR <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location($) t t 7 <br /> t I <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 r <br /> Operator Name " -Where Certified ; r <br /> Plant Location `+ <br /> t <br /> Plant Capacity No. Units Served • f <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 -.�. v" <br /> SIZE: C1 Less Than 1,000 Sq. Ft., ❑ More Than 7,000•Sq. Ftp, �-- ••t3 Lam:t I ,r f <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 accordania with San Joaquin County <br /> ordinances, state laws, and rules a ti ns f e n Joaquin JLocal Health District. <br /> v <br /> APPLICANT'S SIGNATURE X � t <br /> } FOR DEPARTMENT USE ONLY , <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received BylJanuary 31 ❑ July 1 &Received By July 31 <br /> q ° REMIT <br /> BILLING REMITTANCE $ <br /> BASE I EXPLANATION DATE DATE REMITTE AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> s <br /> OTHER <br /> OTHER f <br /> S <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />