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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Applicaikon. ; <br /> APPLICATION <br /> y (For Non-Transferable, Revocable, and Suspendabley y' S'EPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is ade to 9,ry gn1rus ess in the jurisdictional-area of the San Joaquin-Local Health District je, ,~ <br /> yBusiness Name (DBA- jam( Address-/2 c---- <br /> zOwner_ f� L��' ,tj�i" ( Address� <br /> a <br /> Firm Partners, Addresses and Telephone Numbers - <br /> IL Business Telephone No:, Emergency Telephone No. : 'A <br /> Q _ _ r <br /> 1 Contractor Licence No. - ;ry -. .. l <br /> a Applicants Name (Print.) Title' - " Date <br /> PP - <br /> Please check Applicable Category.(1-7).and Fill in the Required Information,.,, ',,"fr <br /> 1. ❑PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ll ¢ <br /> For July 1, June 30,-'19214 -Disposal Sites <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 I� <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 /> Test Location Test Date/Time <br /> 4- ASANITATION PERMIT I: / <br /> 9 , <br /> Job Address/Lo ation <br /> Owner � y i 6`=' Address <br /> � <br /> 13 SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORiARY NEW EPAIR ❑ OTHERCAI <br /> 5. ❑ CHEMICAL TOILETS For.,I July 1, -June 30, 19 .... <br /> Type Construction NDisposal Site <br /> !ll! Equipment Stora a/Cleanin Locations <br /> No. of Units9 9 ( ) , <br /> 6- ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name 0 Where Certified — <br /> Plant Location �r ! <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 thiSjapplicafion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws!and r sa d re dations o e San.Joaquin Local Health District._ r <br /> APPLICANT'S SIGNATUREote <br /> YIIIIII *+r <br /> r , <br /> _ FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 13ANNUALLY�4 j ❑ PE_R UNIT ❑ PER SITE ❑ EACH 0 January i &Received By January 31 © July 1 &Received By July 31 e <br /> p _ REMIT <br /> BASE:I EXPLANATION BILLING I REMITTANCE $ AMOUNT DUE CHECKED <br /> R DATE a DATE m .REMITTED AMOUNT } <br /> FEE14 - <br /> LESS <br /> g F <br /> 1 <br /> PRORATION <br /> PLUS <br /> PENALTY Yf t <br /> OTHER <br /> OTHER. <br /> Received by w Date Receipt N0. _ l Permit No. !ss ance Date 1 Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ��ENVIRONMENTAL HEALTH PERMIT/SERI ICES 1601 E.HAZELTON AVE.,P.O.Bax 2DD9 STOCKTON,CA 95201 + <br /> 'III` <br />