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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. .r <br /> APPLICATION <br /> _ (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> ` LIQUID WASTE <br /> Applica}t'�Is hereby rpadp to carrybusiness in the jurisdictional area of the San Joaq in L I Health Dist I <br /> f y Businoss Name (DBA)L, kALTC14k(9: r) ( gT� Address - eR I <br /> a Owner <br /> Address <br /> Firm Partners, Addresses and T le hone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> ' Contractor Licence No. Q <br /> Applicants Name (Print) 4M, 'tTitle Date <br /> Please check Applicable Category (1-7)anll Fill in the Required Information j <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. j# <br /> CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD z <br /> C For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> 1 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PER <br /> Job Addres Location '3 ,I, r4 �S u� `r�� <br /> Owner 426LOC i IAddress *4/KE . <br /> E!rSEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE'PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 11NEW 11 REPAIR El <br /> � <br /> 5. [1 CHEMICAL TOILETS For July 1, -Ju e 30, 19 - � _ 6 <br /> Type Construction ? V] <br /> No. of Units <br /> Disposal Site <br /> - <br /> Equipment Storage_/Cleaning Location(s) `5' .i 7'` 4`" 4! <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name i Where Certified ) <br /> Plant Location 1 <br /> � 1 <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> s f <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft- art <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> �,l�. , OeJoa� T�rz Lei�. t"e� �a'�G1Q `9C. C�'oel # <br /> Y GeE� T � <br /> I hereby certify that I have pr red this applicatio hat the work will be clone in a ordanceTwith SanJoaquin County i <br /> ordinances, state laws, an r and regulation' t an uin Local Health District.' 1 <br /> �I t <br /> APPLICANT'S SiGNAT <br /> AOR DEPARTMENT USE ONLY, <br /> Fee is Due: ❑ ANNUALLY 4` # f "r x <br /> ❑ PER UNLIT. ❑ PER SITE r" <br /> ` EACH ❑ January 1 & tpiviq;January 31 [] Jtily 1 8 Received By July 31 • <br /> BASE EXRLANATION BILLI REMITTANCE $ _ , REMIT <br /> ' 1 DAD REMITTED���wW-ter rAMOUfJT DUE CHECKED � l <br /> FEE ¢/ F fr" AMOUNT <br /> LESS III ✓ 4 f <br /> PRORATION .! <br /> PLUS � <br /> ^ � <br /> PENALTY <br /> OTHER , <br /> OTHER <br /> Received by Date <br /> Receipt No, Permit No. Is uane Da Mailed <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES Delivere0 - ff <br /> - + ` - - 1801 E.HAZELTO .,P;O.Box 2009 STOCKTON,CA 95201 t I <br />