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F Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> --�- APPLICATION <br /> i (For Non-Transferable, Revocable, and Suspendable) <br /> T ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> 42, 11 LIQUID WASTE <br /> Application is hereb made to carry on business in the jurisdictional area of the San�Joaqui L fcal H Ith District <br /> r y Business Name (DBA) � Ilif t_ dwL� Address <br /> I a Owner Address keii>. <br /> Firm,Partners, Addresses and Telephone Numbers RMC 5y9_44` At1 �SGgLBrL� �a(o3 f' <br /> aBusiness Telephone No. Emergency-Telephone No. <br /> Contractor Licence No. ice_ f <br /> LApplicants Name (Print) ���� 7"bLO ice$ Title Off' 10 Date I � 7I <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. I <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 R.S. or R.C.E. No. <br /> _-Te <br /> st Location Test Date/Time <br /> 4. E SANITATION PERMIT RE 04 0 <br /> Job Address/.Location ' <br /> Owner +�b Address 31144 0., ` <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> i ❑ PERMANENT ❑ TEMPORARY ©NEW ❑ REPAIR ❑ OTHER <br /> r 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 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this ap ion a t the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, d regulat ns of the a J aquin Local Health'District. a <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENY USE ONLY ` <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE IJ EACH ❑ January 1 &Received By January 31 El July 1 &Received By July 31 <br /> BILLING ITTANCE $ REMIT <br /> BASE EXPLANATION' TE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE s <br /> LESS <br /> PRORATION <br /> PLUS - <br /> PENALTY - <br /> OTHER - :! <br /> OTHER F j <br /> 19 7-S <br /> Received by- Date Receipt No, Permit No. Issuance Date 'Mailed DOivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />