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APPLICATION <br /> It,Non-Transferable, Revocable, and Suspendat. SEPTAGE <br /> 'ENVIRONMENTAL HEALTH PERMIT'` <br /> LIQUID WASTE <br /> Application is hereby <br /> � me to car rs in they' ris Ictlonal area of the San oa uin L al lthhDiStrict <br /> EBusinesasame DBAAddres 4_* <br /> >0^ <br /> i Owner Lrry In 00 Z � <br /> kddres§ <br /> Firm Partners, Addresses and Telephone Numbers <br /> iBusiness Telephone No. — Emergency Telephone No. it <br /> Contractor Licence No. <br /> Applicants Name (Print) - ',y�s,o _ _ __1S1(2 1 Title QA- X3L*—Y-- Date Sic,.2— Sl� __,l_ <br /> Please check Applicable Category (1-7)and Fill in the Required Information f A' <br /> 1. El PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) V_ <br /> For July 1, June 30, 19 _ Disposal Sites _. ^ <br /> Description(Make/Yr., Color) <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 <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 /> 9. ❑ SANITATION PERMIT <br /> Job Address/Location - <br /> SO er 45 Atldress <br /> EPTIC TANK CESSPOOL EACHING FIELD ❑ SEEPAGE PIT 13 PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW 11 REPAIR ❑ OTHER <br /> S. ❑ 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 <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 /> V <br /> 1 hereby certify that I have prepared this application and that the.work a don it accordance with San Joaqu' ounty <br /> ordinances,state laws, a rule and regulations f the San Joaqun L al Health Dist 'ct. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE E <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DU NECKED <br /> UNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER CL <br /> OTHER <br /> VIA 61 I Itgj /6-711 <br /> Received by ate c p o. Permit No. Issuance D ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON V ..P.O.Box 2009 STOCKTON,CA 95201 <br />