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Applications Will 8e Processed When Submitted Properly Completed ro� ihe Applica 111UJ <br /> FrkL oT'� P�6T Pk" bl 6�2` APPLICATION _ t� gf1{�1 <br /> (For Non-Transferable, Revocable, and Suspe ) ,SUN 29 170 k <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE J,•[j`x,iJii`� ii-or-AL,. <br /> C 'Ur <br /> L <br /> Application is hereby made to carry on business in the jurisdictional area of the San Ja��'`� ,o> i I�I �[Di�lret <br /> Business Name (DBA)/ Address <br /> a Owner_ (SRL &aLcr(ci4 Address Q6g9q C7rmirgxuC `[Ltd 5%-crLo VCJ <br /> Firm Partners, Addresses and Telephone-Numbers <br /> m Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date 11+1 <br /> Please check Applicable Category(1-7) and Fill in the Required Information .r <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> t For July 1, June 30, 19 Disposal Sites 'r <br /> Description(Make/Yr., Color) 0 <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 <br /> No. of Vehicles Stored <br /> ! <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 / <br /> < b Addr s/Loca -on �� C C �IYI e5sea-A,/7 153 0 <br /> OwnerA�zL CrtGt� Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW XREPAIR ❑ 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, E] LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq- Ft., ❑ More Than 1,000 Sq. Ft. y <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATUR�( <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 11PER SITE EPRTEAGH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> 1 <br /> PLUS <br /> PENALTY <br /> OTHER –` r <br /> y <br /> `=OTHER . _ <br /> { <br /> Received by ate Receipt No. Permit No Issuance Date ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601..E.HAZELTON AYE.,P.D.Box 2009' STOCKTON,CA 95201 <br />