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Applications Will ge Processed When Submitted Properly Completed.Be Sure To Sign The Application. ' <br /> f APPLICATION <br /> (For Non-Transferable;Revocable,and Suspendable) ` <br /> >' ENVIRONMENTAL HEALTH-PERMIT SEPTAGE 4 <br /> `f LIQUID WASTE .. ` <br /> Applica ion is hereby made-to rr� n 'ness in t e' risdictiornal area of th�u�n�oauinLocal ealth Di trio e <br /> Business Name(DBA) <br /> z�Owner 9 : Address - ` <br /> t3Address 1 <br /> r Firm Partners,Addresses and&Vp ne Numbers -• - <br /> Business Telephone No, <br /> Contractor Llcence:Ni Emergency Telephone No. <br /> E L Applicants Name(Print) - <br /> Please check Applicable Category Title' <br /> e�ry('#-7)and Fill in the Required Information _ <br /> ❑ PUMPER VEHfGLE PERMIT REGISTRATION(FOR EACH! VEHICLE)For Jul 1, June 30;t9 <br /> C <br /> Disposal Sites <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL.License No. _ <br /> Capacity---•-- T.�.-i—.a - LAL.License Renewal No. <br /> G�1';Weights&`Measures'1Vv:—�••� �-.r:'•�•-..� ���•._ ' <br /> Equipment Parking Address' <br /> 2. ❑ PUMPER YARD <br /> 'ForJufyl;•.,. -•••,•June-30;1$-------.:.'-.� <br /> ' No.of Vehicles StoredNo.of Chemical Toilets Stored <br /> 3. O PERCOLATION TEST -------------- <br /> ,g _ <br /> R.S.br R.C.E. Name <br /> TesilLocation R.S.or R.C.E. N61/a 'Y �s <br /> 4. 13 SANITATION PE T <br /> Job Ad Test Date/Time <br /> � <br /> ? Y <br /> I <br /> . s/ ocatlon -I ��- � '�'� � x t � <br /> I Owner _ Q <br /> SEPTIC TANK i;ESSP00 Addres§`rte f <br /> �+ <br /> PERMANENT ❑ TEMPpRARY EACHING �IELQ agEEPAGE PTS PACKAGE PLWNT ; <br /> EW' ❑ REPAIR,, ❑ OTHER <br /> 5. <br /> CHEMICAL TOILETS For July 1,- una 30, 19 r. p n 611U. ,�. <br /> Type Construction ; Disposal Site l�rt�•' �y �` <br /> No.of Units <br /> Equipment,Strigo/•Clea ITfng Lncat;on(s), <br /> 6. D PACKAGE TREATMENT PLANT For July„1.;-June 3Q 19 i <br /> Operator Name 1 <br /> Plant Location "F - Where Certified <br /> PiantCapacity - !rte '•r' 1 i _ <br /> G <br /> 7, ❑ No.Units served <br /> LAUNDRY For July 1,-June 30,19-- ' 1 _ 1 <br /> SIZE. 13Less Than 1000 Sq. Ft:, r ❑ More Th'an 1,000 Sq. Ft. , �- <br /> ❑ DRY CLEANING,Chemicals.Used/Amount/•Mo. t <br /> fh –F <br /> hereby ceftlfy-that 1 have prepare is ep Iication nd that the work will be done in accordance with San Joaquin Count <br /> ordinances,s e laws, d rules and uta Sari J y <br /> q 1 Ocal Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMEN rI�SE ONLY <br /> Fee I9 Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SrTE <br /> EACH ❑ January 1$keceivetl By Januar 31 <br /> Y ❑July 1&Received By July 31 <br /> a BASE EXPLANATION BILLING hEMITTANCE § REMIT <br /> DATE DATE REMITTED AMOUNT DUE <br /> CHECKED ; <br /> FEE + ' AMOUNT <br /> } LESS - <br /> _ PRORATfON ' <br /> PLUS <br /> I PENALTY 0. - <br /> - <br /> OTHER <br /> • OTHER <br /> Aeceved.Dy Date i Receipt Na ? r. 1• kI PERMrTPJe9rERiYt No., <br /> •. ' <br /> ::A <br /> APPLCANT—RETURN ALL COPIES TO: Delivered YICES .�.� <br /> �. <br /> } 1991 E.NAYELTO .•P.O.13OX 2009 STOCKTON.CA 95201' F <br /> b , <br />