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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION k <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ' ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE I <br /> Application is reby made t9 carry on b iness in the juri ictional area of the SaQ Joaquin Local Health Dist�a -� <br /> y Business Name (DBA) Address 7F- <br /> aOwner +�1Z _ Address <br /> 7 Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No.T3 r Q Emergency Telephone No. <br /> Contractor Licence No. Z ;-7- <br /> L Applicants Name (Print) _ Title Date _ ga <br /> Please check Applicable Category (1-7)and Fell in the Required Information <br /> 1. ❑`PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,. r.. June 30. 19 Disposal Sites St. <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity,_ * Gal., Weights & Measures No. <br /> Equipment Parking Address "' `e ` + TA 'r91 L <br /> 2. ❑'PUMPER YARD> .t' <br /> For July 1, June 30; 19 r <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored 1 <br /> 3. ❑ PERCOLATION TEST ;I <br /> R.S. or R' .E. Name R.S. or R.C.E. No. + <br /> Test L ation Test Date/Time r <br /> 4. SANITATION PERMIT <br /> Job Address/Locati n 2-z — --'- <br /> Ower ft�t-r-�r �!F __.' ___Q�� Address <br /> til SEPTIC TANK ❑ f ESSPOOL BLEACHING FIELD ❑ T ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER D <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> • C <br /> Type Construction Disposal'Site <br /> No. of Units Equipment Storage/Cleaning Location(s)� F* <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location t� _ <br /> Plant Capacity No. Units Servers <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 K 4, <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ ORY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance wit, San Joaquin County <br /> ordinances, state laws, and rules-and regulations of the San Joaquin Local Health District. KUCJ <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ J nary 1 &RqIZ�dBy nuary 31 ❑ July 1 &Received By July 31 <br /> REMIT. <br /> BILLING REMITTAN E $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED t <br /> '`� AMOUNT <br /> FEE If X0-0 - - `� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> d 7 l2 r 6 G � n <br /> Received by Date Receipt No. Perm' No, Issuance ate Mai d Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH ERMIT/SERVICES:, 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />