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S Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ,ter <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE400/ <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> 0 Business Name (DBA) -D•Q- <br /> I- ! Address a-l!� <br /> a Owner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. � �G—9 Ga Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) f Title QST" I <br /> Please check Applicable Category i Date Z-' 7-8 �o <br /> PP g ry (1-7}antll 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. f <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD aft <br /> For July 1, June 30, 19 N� # <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.G.E. No. `7 <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location 4,2 <br /> Owner \ ' * E sJ Address 4ff <br /> ❑ SEPTIC TANK'•:, ^❑ CESSPOOL LEACHING FIELD X SEEPAGE PIT ❑ PACKAGE PLANT <br /> PKPERMANENT ❑.TEMPORARY ❑ NEW (REPAIR ❑ 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, IJ 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 application and that the work will be done in accordance with San Joa uin Countyordinances, state laws, and rules and regulations n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X. <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Dile: 11ANNUALLY <br /> ❑ PER UNIT; ❑ PER SITE ❑ EACH ❑ i <br /> 1 &Received ceved B Januar <br /> _ y Y 31 El 1 &Received By July 31 <br /> BASE EXPLANATION BILLING '-REMITT CIE— $ - REMIT <br /> i� DATE D REMITTED AMOUNT DUE CHECKED <br /> FEE <br /> AMOUNT I <br /> LESS <br /> 1 <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER l <br /> OTHER i d <br /> �-6y Date <br /> Receipt No. Permi[No. suance pate Mailed <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES. - Delivered <br /> .y 1601 E.HAZELTON AVE.,P.Q.Box 209 STOCKTON,CA 95201 t <br />