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APPLICATION <br /> l 1 "ter Non-Transferable,'Revocable,and Suspenda'. !. SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT ] <br /> LIQUID WASTE <br /> Appl ication is hereby made to carry on business in the jurisdictional area of the <br /> San oNav LoeaUl�Health i�Ckt(7n r Ca <br /> Address <br /> N Business Name (DBCGT'-q-NAddress Nf ti C • r Ste- — <br /> z Owner E�4 Q►...-. z NfCK.. �._'... <br /> j Firm Partners, Addresses and Telephone Numbers 6 )4)— � <br /> Emergency Telephone No._L <br /> a Business Telephone No. ZO9� '$ 7 <br /> bU <br /> Contractor Licence Na. . G = Date <br /> Title .E-- EA1PI+OS I <br /> �Applicants Name (Print) <br /> l i and.Fill in the Required Information <br /> Please check Applicable Category ( - ) - s <br /> 1. © PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July'1, ��.._: Julie 30: 194== '- Disposal-Sites - <br /> Description(Make/Yr.,Color) t", CAL. License Renewal No._.. <br /> Serial No. ' CAL. License No- <br /> Capacity------L-- <br /> oCapacity _ Gal.,Weights&Measures No. <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. Qk PERCOLATION TEST �-1'� [ J `f (S. or R.C.E. No. <br /> R.S. or R.0-E."Name Test Date/Time <br /> Test Location -7 <br /> �j <br /> 4. ElSANITATION PERMIT -� / <br /> Job Address/Location Address <br /> Owner ❑ LEACHING FIELD C3 SEEPAGE PIT El PACKAGE PLANT <br /> ❑ SEPTiC TANK 11 CESSPOOL ❑ REPAIR © OTHER <br /> i ❑ PERMANENT ❑ TEMPORARY ❑ NEW <br /> ' 5, ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposai-Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑.PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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 <br /> hereby certlfy Ye prepared this application-and that the work +evil! be"done in accordance with Sari "Joaquin County M <br /> ordinances, st a laws, a rut s an regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X JE S WRY,- P P. <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> 31 <br /> 1 <br /> Fee Is Due: ❑ ANNUALLY PER UNIT PER SITE EACH ❑ January 1 &Received By January 31 July t &'Receiv RJuly <br /> EMIT <br /> BILLING REMITTANCE s AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS — <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> R � _ <br /> Receipt No, <br /> Reced by Date Permit No- Issuance Date 'Mailed Delivered <br /> Oi £NYiRONMENTAi HEALTH PEAMlTiSEAY10E5'�`"— -�1601 E.HA2ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT--RETURN ALL COPIES T <br />