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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendabie) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE E <br /> Applicati AreAy rrla eto carryo usin s In thejyxisdictional area of the Sa doaqui calks Ith Distri�ty <br /> Business N (DBA) �1 �c='s n� '� Address �� <br /> .4 Owner 'r ft1 CAA61le- <br /> Address <br /> -Firm Partners, Addresses and I hone Numbers <br /> a Business Telephone No. Emergency Telephone No. <br /> y <br /> Contractor Licence No. 1 <br /> L Applicants Name (Print) 1 m (?AQt:-st)E Title Date <br /> Please check Applicable Category i <br /> PP g ry (1-7) and Fill in the Required Information 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, M June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) � <br /> Serial No. CAL. License No. CAL. Licc,se Renewal No, r� � <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 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 /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT ! 1 <br /> Job Address/Location 17,221 r /-/Lv 120 <br /> Owner u 7'k-/,v Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW IO REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 L� a <br /> Type Construction i Disposal Site�A 0 Tlz a k'lSTI U6 �y <br /> No. of Units Equipment Storage/Cleaning Location(s) >eblicr vV <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 i <br /> Operator Name Where Certified ' <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 ( s <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> �r <br /> I ' <br /> I hereby certify that 1 have prepared this application and thatL the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the SarAJ <br /> oaquin Local Health.District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 Cl July 11 Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> GATE DATE REMITTED ; j" <br /> �y AMOUNT ; <br /> FEE �S ��✓ 1 ( 4 <br /> LESS 'E <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r <br /> OTHER <br /> Receitl by fDale Receipt No "+ ...-Permit No.- y. Jssuan a Date.^ ed Delivered <br /> MIS <br /> _ � g f <br /> APPLICANT—.RETURN ALL COPIES TO: ENVIRONMENTALHEALTHPERMIT/SERVICES_ ., .-- 1601 E.HgZELTON-AYE.,P.O.Box 2009 STOCKTON,CA 95201_ <br />