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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> _ APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE A <br /> (DBA) <br /> pp ) y +carryon jurisdictional area of the San Joaqui n Local Health District <br /> Z <br /> Business Name (DBA <br /> Application t�e eAl, ('e j Sr,07 & S t+.'� Address_99 6_3 ,Scar C� C� /r f1?_ <br /> a <br /> owner rr/�' E i� ,P .f Address Y S'� CJ;w a leI6-lef <br /> Firm Partners, Addresses and Telephone Numbers <br /> E Business Telephone No. � Emergency Telephone No. <br /> f _JContractor Licence No. -7 r <br /> y L Applicants Name (Print} +t` TitleCLL' tater <br /> Please check Applicable Category (1-7)and Fill in the Required-information MS So. Oro * Stoc(ttofl, Ceiff. 95206 <br /> 1. 1:1 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) V_ .) 2�5 ' <br /> �A11trvtAr'3 Q& <br /> For July 1, June 30, 19 � Disposal Sites +cam <br /> Description(Make/Yr., Color) <br /> Serial No. I 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 /> y <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> t Test Location t Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location 7 <br /> Owner tif� �C�S Address r S" <br /> F ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD XSEFPAGE PIT IJ PACKAGE PLANT <br /> f ❑ PERMANENT ❑ TEMPORARY ❑ NEWREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <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 MARENCE'S SEPTIC & SEWER SERVIOE <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,. ❑ More Than 1,000 Sq. Ft. Zai So. Oro * Stochton, C2'K 95205 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. F, . - •s•32a9 QBntro4Ar'3tj0^ <br /> i <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, a=ru+69-�Lpd- onsof the San Joaquin ocal Health District. <br />'r APPLICANT'S SIGN TUREX Age <br /> o — <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 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> � AMOUNT <br /> FEE L4,S L ICS <br /> i LESS <br /> PRORATION <br /> I PLUS <br /> PENALTY <br /> t <br />{I` OTHER <br /> k OTHER t - <br /> Received by bate - Receipt No. Permit No. Issuance Date Mailed - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201 <br />