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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 isMhC�Oy rrt de t ar�r�Cn trsir} s�n the�uCriisdictional area of the San Joaquin Lvcal Health District <br /> On Business Name (DBA) Tia I C7 J p i I K Address 4545 H31 dreth Lane <br /> z Owner Address Same <br /> % <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. - Emergency Telephone No. 957-4027 <br /> i <br /> Contractor Licence No. 10 171 <br /> � <br /> Applicants Name (Print) Title r Date i <br /> Please check Applicable Category (1-7) and Fill in the Required information <br /> 1. © PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> i <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL.. Licc ise Renewal No. <br /> y <br /> Capacity Gal.,Weights & Measures No. <br /> a <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 Teg�D a/Ti e / <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location 6` <br /> Owner Addr rrrrs�� to <br /> I(SEPTIC TANK CESSPOOL LEACHING FIELD ISI SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW REPAIR ❑ OTHER - <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 n <br /> Plant Location tA, <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. <br /> ❑ <br /> DRY CLEANING, Chemicals Used/Amount/Mo. <br />'f 1 <br /> Ij I hereby certify that I have prepared this application and that the work will be done i d anc e with San Joaquin County <br /> ordinances, state laws, and rules and regulations oft San Joaquin Local He th Dist i <br /> APPLICANT'S SIGNATURE X aT� <br /> t / / ' -----_- <br /> r. <br /> FOR DEPARTMEN• SE Y <br /> Fee Is Due: ❑-.ANNUALLY © PER UNIT ❑ PER SITE ❑ EACH uary 1 &Received By January 31 ❑ July t &Received By July 31 <br /> I: REMIT <br /> BASE EXPLANATION BILLING RE ANCE $ AMOUNT DUE CHECKED <br /> i DATE ATE REMITTED C� AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r Received by Date Receipt No. -Permit No. "IssuarIce Mailed Delivered <br /> r APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON irfP.D.R 26o9 STOCKTON,CA 95201 <br />