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j APPLICATION Non-Transferable, Revocable, and-Suspendat�`'1t <br /> ENVIRONMENTAL HEALTH PERMIT'''' SEPTAGE <br /> LIQUID WASTE <br /> Application is hereb ade to carry on b "'ness in the'uns ictional area of th Jo quin Local H alth Distriqt. <br /> s . <br /> 1 <br /> ' 3usiness Name (DBA) _ Address �tT, " <br /> z Owner Address <br /> P,._-Firm Partners, Addresses and Telephone Numbers ' <br /> 3usiness Telephone No. Emergency Telephone No. <br /> c=ontractor Licence No. <br /> a Applicants Name (Print) ' .. �" . Title a r _T? Date" ' <br /> .lease check Applicable Category (1-7)and Fill in the Required Information c�1 <br /> k 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> I For July 1, June 30, 19 Disposal Sites VN <br /> rescription(Make/Y_r_, Color) UIQ <br /> Derial No. CAL, License No. CAL. License Renewal No. <br /> t "Capacity Gal., Weights & Measures No. <br /> —Equipment Parking Address <br /> ❑ PUMPER YARD <br /> Lor July 1, June 30, 19 <br />` No. of Vehicles Stored ` <br /> F-No. of Chemical Toilets Stored <br /> i, ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> FTest Location Test Date/Time <br /> C SANITATION PERMIT <br /> r Job Address/ ovation _ 1J{ - a <br /> .Owner— '�� �- Address <br /> (❑ SEPTIC TANK ❑ CESSPOOL �LEACHING.FIELD ,SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR 0 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,_June 30, 19 <br /> Qype Construction Disposal Site <br /> oofUnits Equipment Storage/Cleaning Location(s)❑ PACKAGE TREATMENT PLANT For July,1;-.June 30, 19 <br /> Operator Name Where Certified <br /> I Plant Location <br /> —Plant Capacity No. Units Served <br />` 7. ❑ LAUNDRY For July 1;--June 30,-,19 - - <br /> I `SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1;000 Sq. Fl <br /> DRY CLEANING, Chemicals"Used/Amount/Mo.. <br /> I hereby certify that.]'have prepared..this application and that the work will be done in accordance with San Joaquin County <br /> l ordinances,state laws;"and rule�qne tf�y San Joaquin Local.Health District. <br /> FiAPPLICANT'S SIGNATURE X <br /> I _ - <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceWed:$y July 31 <br /> BILLING REMITTANCE $ REINIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE_-. ... DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRONATION <br /> PLUS <br /> I PENALTY - <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. -IjdsuEkkee Date sited Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVIGES -1691 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />