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Applications 16WDProcessed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ` SEP 7 1979 APPLICATION ------ <br /> . . (For Non-Transferable;Revocable, and Suspendable) X0 SEPTAGE <br /> SSAN JC}A�UI€'�I 4 ,�. �,L ENVIRONMENTAL HEALTH PERMIT - <br /> LIQUID'WASTE <br /> HEppLT.H GIS I, _ <br /> �tppllcation Is herebymade to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) 2711 in C!oc a Address <br /> a Owner Address 60 <br /> 77 <br /> 01 Firm Partners, Addresses and Telephone Numbers /�'C� R01:fCL" <br /> CL Business Telephone No. — - z Emergency Telephone No. <br /> Contractor Licence No. - <br /> Applicants Name (Print) TitleDate <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) ' <br /> Serial No. CAL. License No. CAL. License Renewal No. _ e <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 /> No. of Chemical Toilets Stored pi <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. IC SANITATION PERMI -� <br /> Job Address/Location <br /> Owner Address== <br /> SEPTIC TANK 11 CESSPOOL IQ LEACHING FIELD ❑ SEEPAGE PIT" ❑PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER- a . <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> r 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 /> i. Plant Location <br /> Plant Capacity No. Units Served r <br /> 7. ❑ LAUNDRY For July 1, -June 30,`19 Tj <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. r _ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Mordinances, state laws, and es and regula • sof th�Sa oaquin Local Health District, Ir <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 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE "EXPUA�NATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> - DATE DATE REMITTED AMOUNT <br /> r FEE `t !�o <br /> LESS <br /> PRORATION <br /> t PLUS <br /> PENALTY ` <br /> OTHER <br /> 5� <br /> ` OTHER ` <br /> ..7-7 <br /> Received by- Date-- Receipt No. ermil No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:, ENVIRONMENTAL'HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - 1 <br />