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�f Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION � 4/� <br /> r Oc- <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT 3 V <br /> LIQUID WASTE <br /> Application is hereby made to c r on bu ' sus in t1he�j risdictional area of the an Joaquin L cal Health h Distric`� <br /> Business Name(DBA) i n-JS. AddrePiLss <br /> I z Owner��. gt � <br /> Address <br /> u Firm Partners, Addresses a T lephone Numbers <br /> Emergency Telephone No. <br /> a Business Telephone No- -- r <br /> a <br /> Contractor Licence No. .. <br /> a �F..F i fl 1 tZ�.+� Title r ate <br /> C APplicantName(Pont)`_. <br /> Please check Applicable Category(1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER.VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For J. 4" t `j�` June 30, 1, :: - - Disposal Sites <br /> 1 <br /> Description(Make/Yr., Color) _ <br /> Serial No. 'CAL.License No. F -CAL. <br /> P License Renewal No.— <br /> 'Capacity, -Gal.,,Weights-&-Measures-No. <br /> Equipment Parking Address <br /> t e �!L <br /> --- <br /> 2. ❑ PUMPER YARD <br /> For July 1, . June 30, 19 <br /> No. of Vehicles Stored - <br /> No.of Chemical Toilets Stored <br /> 3—. 0 PERC;OL-ATION-TEST.—+- <br /> t R.S:`Olr R.C.E. No. ) <br /> R.S.or A.C.E.Name <br /> Test Location ' ' T' Test Date/Time <br /> 4. 0 SANITATION PE I '.� { i <br /> Job Addr /L c do <br /> Owner4-51 Address <br /> SEPTIC TANK ❑ CESSPOOL 'LEACHING FIELD ('SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ P{.ERMANENT ❑ TEMPORARY c rNEW "REPAIR ❑ OTHER <br /> ! 5. ❑ CHEMICAL TOILETS For July 1.`-June 30, <br /> Type Construction - Disposal'Site <br /> No. �f Units __ Equipment Storage/,Cleaning Location(s) ) ( 1 ( r <br /> b:' ❑ PACKAGE TREATMENT PLANT For July 1, -June D0, 19 I l <br /> 1 l w- <br /> Opeiator Name f I Where Certified <br /> Plant Location I �� �,� 1 - • <br /> E- ---- .lJnits Served <br /> •,Plant Capacity ttt' r <- 1 3 • ter <br /> 7. 0 LAUNDRY For July 1, -June 30, 19 ' I <br /> i <br /> /SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More han 0 Sq, Ft. <br /> ❑iDRY CLEANING, Chemicals Used/Amount/M-0—C-1 t - <br /> F ' W ty,1 • <br /> I hereby certii ve prepared this application and t i'the work will be done in-accordance with San Joaquin County s1, <br /> ordinances,state laws, an ul: and 'el ti <br /> �uons o theva <br /> _San qui Local Health District. <br /> r _ { <br /> APPLICANT'S SIGNATURE X + N <br /> ' 1 t <br /> i s <br /> t. FOR DEPARTMENT USE ONLY ` <br /> ip Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE C1 EACH: ❑ January 1 A Received ey January 31 ❑ July &Received By July 31 <br /> REMIT r <br /> BASE EXPLANATIONBILLING REMITTANCE t $ AMOUNT DUE CHECKED <br /> DATE DATE I REMITTED 'AMOUNT { <br /> I FEE r _ f <br /> 1 LESS <br /> PRORATION <br /> } PLUS <br /> PENALTY -- <br /> OTHER - r <br /> 1 <br /> OTHER L <br /> Received by Date •Receipt No. Permit No. { I sa ncc: ate at Delivemd <br /> APPLICANT—REPJRN-ALL S OPIE5 TO: ENVIRONMENTAL HEALTH PERMITISERVICES J 1601 E.HAZPLTON AVE.,P. 2009 STOCNTON,CA 8520* <br />