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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).� `4 ,SEPTAGE. F, <br /> 1 3�ri <br /> ENVIRONMENTAL HEALTH-PERMIT` ' �" <br /> LIQUID WASTE <br /> Applica n is here mad ma a to carry of�busine s In the urisdictional area of th an Jo uin Local Health Di trict <br /> H Business Name (DBA)�• A-04 l�lF� .����Address�a .,56- t� � 9J <br /> aOwner Y A- Address <br /> J Firm Partners, Addresses and Telephone bWmbers <br /> a. Business Telephone No. Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> Applicants Name (Print) V sa Title�g�( Al Date <br /> Please check Applicable Category (1-7) and-Fill in the Required.lnformation_.s 0.11:;qk,,,J,._ =r, <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,7 -'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 i <br /> e <br /> .No.of Vehicles Stored <br /> No. of Chemical Toilets Stored . <br /> 3. J❑ PERCOLATION TEST <br /> R.S.nor R.C.E. Name' R.S. or R.C.E. No. <br /> Test L'4"OR Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location �g��— <br /> Owner �� Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR %()TRIER 1,46jj� `7�q <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 0. f a <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. 11 LAUNDRY For.July 1, -.June.30, 19 <br /> ZE <br /> SI : 13Less Than'1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r <br /> { <br /> + I hereby certify that I haAiepared this a plicatiWanhat th work w'll be done in accordance with San Joaquin County +� <br /> ordinances, state Iaws d re tio_ris oJ aqui Local _.ealth•bistrict. - <br /> APPLICANT'S SIGNATURE X ` dl <br /> s: t FOR DEPARTMENT,USE..ONLY �,,` <br /> Fee Is Due: ❑ ANNUALLY _ ��PER UNIT ❑ PER SITE 11 EACH Q January ceived By January 31- ❑ July 1 &Received By July 31 <br /> a; REMIT <br /> F s I BILLING REMITTANC " `.,. AMOUNT DUE CHECKED <br /> RASE EXPLANATION <br /> i DATE, T ' i SRI M'ITTED I AMOUNT <br /> FEE <br /> t , <br /> LESS -- <br /> PRORATION <br /> PLUS : <br /> PENALTY <br /> OTHER <br /> 3 _OTHER +. y <br /> -� s i Y <br /> Received by -- Date Receipt No, Permit No. - ifsuancd Daie. Mailed .Delivered x <br /> .APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL.HEALTH PEAMIT/SERVICES 1601 E:HAZECTON°AYE.,P.O.Bax 2009 STOCKTON,CA 95201' <br />