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ar Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> `= APPLICATION <br />' E <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatiojereby m e Y carry o iness in the jurisdictional area of tyaquin L He tact <br />- y Business Name (DBA) L� iT Address <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses an el hone Num ers <br /> CL <br /> Business Telephone No. �'.�35 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Na Title 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) <br /> Serial No. CAL. License No. Tr CAL. Licc Ise Renewal No. <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 <br /> 3. ❑ PERCOLATION TEST - <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location - [ € TesE to/Time` <br /> 4. ❑ SANITATION PER <br /> Job Address/Lo CrG T7 Q C <br /> Owner T Address a <br /> SEPTIC TANK ❑ CE OL EACHING FIELD '❑ SEEPAGE PIT ❑ PACKAGE PLANT G� s <br /> PERMANENT ❑ TEMPORARY NEW /XI—F, <br /> EPAIR ❑ OTHER / I <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction - Disposal Site k , <br /> No. of Units Equipment Storage/Cleaning Location(s) i. <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30,19 :r <br /> Operator Name Where Certified <br /> t <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. Ft. i <br /> t <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prep d i_s,application an ork will be done in accord ancewith San Joaquin County <br /> ordinances, state law la re in oc alt District. ' <br /> APPLICANT'S SIGN <br /> s r <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 11ANNUALLY' ❑ PER UNIT.` ••--❑ PER SITE C1EACH 11Jansuary 1 &Received By January 31 ❑ July,1 &Received By Jury 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> c AMOUNT <br /> FEE {v t S 4 �3 <br /> LESS <br /> PRORATION <br /> PLUS 1 /{ <br /> PENALTY S )� f <br />• OTHER <br /> OTHER k <br /> Received by - - - Date Receipt No. Permit No. _ Issuance Date7 Mailed Delivered <br /> APPLICANT—RETURN ALL.COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES''" 1601-E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />