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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> Y (For Non-Transferable, Revocable,'and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT / SEPTAGE <br /> b,nv j` G LIQUID WASTE <br /> 22i3 2-SO <br /> Application is hereby maje to carry on business in the jurisdictional area of the Sa,r$-�aquin Local Health istrict <br /> Business Name (DBA) Address__ 6 a� 1 � •� <br /> aOwner "'f�- Address <br /> J Firm Partners, Addresses and Telephone Numbers _ <br /> aBusiness Telephone No. �7_ �. _ Emergency Telephone No. <br /> aContractor Licence No. 4? P� _� <br /> L Applicants Name (Print) _, Title �-=ri Date <br /> Please check Applicable Category(1-7) and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) - <br /> r <br /> For July 1, June 30, 19 Disposal Sites - <br /> f . <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No., CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures Nod-t <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30,119 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stared <br /> 3. ❑ PERCOLATION TEST } <br /> R.S. or R.C.E. Name f R.S. or R.0-E. No. W <br /> Test Location Test Date/Time <br /> 4. 0 SANITATION PERMIT _ t <br /> Job Address/Location tel/ O <br /> Owner - Address i <br /> P,,SfPTIC TANK ❑ CESSPOOL EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑..TEMPORARY ❑ NEW ❑ RE AIRS 4 -.. ❑ OTHER <br /> 5. 13or <br /> CHEMICAL TOILETS F "Jiine <br /> ly�1,'-Jti ,30, 19 <br /> Type Construction '`' Disposal Site i <br /> t. No, of Units s �' t-- 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 /> j Plant Capacity No. Units Served A ` ' <br /> t <br /> 7. ❑ LAUNDRY—For-July 1; June-30­19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. . <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. z <br /> IT <br /> � I , <br /> t' I hereby certify that I have prepared this application andYthat the work will be done in accordance with San Joaquin County <br /> ` ordinances, state laws, and rules and regu tions f the Sa'n Joaquin,Local.Health-District. <br /> rAPPLICANT'S SIGNATURE X <br /> t FOR DEPARTMENTUSE ONLY <br /> i <br /> Fee Is Due: ❑ ANNUALLY PER UNIT PER SITE EACH ❑,January 1 Received�Ry January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> f c-4 BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE ! REMITTED AMOUNT <br /> 1 F FEE ')715 CL <br /> Y <br /> LESS AAM11 r.�'T <br /> . t PRORATION <br /> PLUS �. <br /> `_- OTHER e.y tom' <br /> OTHER <br /> lo -766 S/ <br /> AL a444k, <br /> Received by - Date - Receipt No, Permit No. t - I uanc Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601-E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />