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`� APPLICATION n <br /> (Far Non-Transferable, Revocable,and Suspendpule) <br /> I ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> I � ' <br /> LIQUID WASTE <br /> Application is hereby read o Carry on business in the jurisdictional area of the San Joaquin Local Health (strict <br /> I H Business Name (DSA) G1U Address ��6� & ��--yam <br /> 1 i Owner— L. <br /> aAddress_��`7,Z3— <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. G r � G Emergency Telephone No. <br /> a Contractor Licence No. <br /> a Applicants Name {Print) �• !=t^ ,I Date 1T�4f <br /> L Title _- 2 1 <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 /> r- <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity 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 1 <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. q SANITATION PERMIT <br /> n f <br /> Job Address/Location <br /> OwnerAddress <br /> VEE TIC TANK CESSPOOL LEACHING FIELD SEEPAGE PIT 13 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 Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name .Where Certified <br /> Plant Location <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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, and I and regulatioi s of he S Joaquin Local Health District. <br /> APPLICANT'S SIGNATUREX <br /> i <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 &Received By July 31 <br /> REMIT I <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED , <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION J„rj <br /> PLUS <br /> PENALTY { Y <br /> i <br /> OTHER r <br /> OTHER P <br /> o f aAq:. .a <br /> Received by Date Receipt No. Permit No. Issuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,-P.O.BP x 2100911��STOCKTON,-CA 95201 '1 2 <br />