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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 Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on siness in the jurisdictional area of the Sa�oaquin Local Health District <br /> Business Name (DBA) GC-7 —Address—./LG <br /> e Owner - �.1 1z <br /> . Address Ge/ 7rl LrGAIX <br /> J Firm Partners, Addresses and Telephone Numbers <br /> M Business Telephone No. <br /> a ,� Emergency Telephone No. <br /> Contractor Licence No. 102 76- <br /> L Applicants Name (Print) Title C ILE 4 <br /> Date <br /> Please check Applicable Category (1-7)and 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) Q' <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 /> i <br /> For July 1, June 30, 19 j <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 l <br /> J 11 SANITATION PERMIT f /'� _Pd^� 1 <br /> _ Ccs C. / �`� <br /> Job Address/Loc tion <br /> O,.,,w, nne�er 7'bw +Nuh Address T <br /> V'SEPTIC TANK ❑ CESSPOOL -t-EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 I; <br /> Type Construction Disposal Site i <br /> `{ <br /> No. of Units Equipment Storage/Gleaning 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. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. FL <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 hereby certify that I have prepared this a plication and-that-the work will be done in accordance with San Joaquin-County <br /> ordinances, state laws, and rules and re ions o an Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X t {' <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH - ❑ January 1 8&Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE <br /> BILLING REMITTANCE' $ REMIT <br /> - EXPLANATION AMOUNT DUE _ CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS /1 <br /> PENALTY or L <br /> OTHER <br /> r <br /> OTHER <br /> C7 <br /> Received by Date Receipt No. Permit No. Issua ce Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boy 2009 STOCKTON,CA 95201 <br />