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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Applic tion. 1 <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable)- <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> i <br /> s LIQUID WASTE <br /> Application is hereby made carry on-business in the jurisdictional area of the Sa aquin-Local Health District <br /> N Business Name (DBA)X04�'t ld4i�M Address <br /> P_ <br /> Owner r Address <br /> Firm Partners, Addresses and Telephone Numbe s <br /> a Business Telephone No. _ `� Emergency Telephone No. <br /> a <br /> Contractor Licence No. <br /> �Applican'ts Name (Print) 11ZI � Title hate v t <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.Z❑ PUMPER YARD` ' /" <br /> f "{ <br /> For July 1, June 30, 19 p, <br /> No. of Vehicles Stored �! <br /> No. of Chemical Toilets Stored <br /> '3. -d PERCOLATION TEST f <br /> R.SYor`R.C.E. Name R.S. or R.C.E. No. i <br /> ash-bcation Test Date/Time <br /> 4 *❑ SANITATION PERMIT _. <br /> Job Address/Location w ti <br /> 1 7,41 <br /> Owner. Address <br /> -.,1 PTIC TANK 11 CESSPOOL 0-17EACHING FIELD ❑ SEEPAGE PIT PACKAGE AN7 t <br /> C� PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHERS <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 '"" <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 /> Pjant Location - - --- <br /> Plant Capacity No. Units Served <br /> T ❑ 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. F <br /> I herrebyrcerti�yt at I have prepared this application and that the work will be done in accordance witli San Joaquin County <br /> ordinances, state laws, and rules and re lati f the Sa aquin Local Health District. n <br /> APPLICANTS SIGNATUREX � <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January-&Received,By Jaruary'31 � ❑ Jufy 1 &Received By July 31 <br /> BILLING '1,- REMITTANC � REMIT <br /> 110 BASF EXPLANATION DATE a DATE - ''REMITTED AMOUNT NT DUE CHECKED <br /> _ �,. AMOUNT <br /> EE <br /> I <br /> a <br /> LESS <br /> PRORATION - ms's J19— <br /> PLUS <br /> ` - <br /> G p \ k <br /> I PENALTY * GrIVp r ` <br /> OTHER <br /> OTHER <br /> �� si <br /> _r,Received by :w Date Rece pt Nv P,ermit,No. ,,, ssuanc Dat _Mailed, Delivered _-�.,, — „y <br /> - - - - i"'..s, _ <br /> PPL•1EANTRETVRXI ALL GO?iE:S TOi ENVIRONMENTAL HEALTH-PERMIT/SERVICES -1601 E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 95201 <br /> . may$:.• '..r...�.... <br />