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Applications Will 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 business in the jurisdictional area of th an J quin Local Health District <br /> m Business Name (DBA) Address, C2 d[ �4Sc7 a�7'Ki�� ��LC1 <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers t <br /> IL <br /> Business Telephone No. .�. �07 Emergency Telephone No. <br /> Contractor Licence No. ���" �3 ' <br /> Applicants Name (Print). 5 _ Title E��Ac 6+7434 Date A9 13_RED + <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. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For Jury 1, June 30, 19 <br /> No, of Vehicles Stored <br /> No. of Chemical Toilets Stored d <br /> 3. ❑ PERCOLATION TEST -' <br /> s <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. j <br /> Test Loc ' n Test Date/Time <br /> 4. PISANITATION PERMIT a <br /> Job Address/Location ���� 6- ��E� etlS eal �� J <br />- ,Own r ���` e 4 gL•� Address wcn <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT- ❑ PACKAGE PLANT r <br /> ❑P RMANENT ❑ TEMPORARY EW 2'REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 p� <br /> 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 /> Plant Location <br /> Plant Capacity No. Units Served r <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I hav prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, ules and r gulations the S Joaqdin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> W� ' <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 i <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LE55 t <br /> PRORATION 1. , <br /> PLUS <br /> PENALTY <br /> OTHER / <br /> OTHER 1 r <br /> eB3�3 161'o. B o agI <br /> Received by Date Receipt No. Permit No. Is uance Qat Mailed l5ellvered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2,009 STOCKTON,CA 95201 <br />