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mlipllcauurla Twill OC reln;csaru pflCll ou171fHlleu I-ruperly Ir0111pletwu. oC Aure I v-alyll I lla P%ppllcallull. <br /> APPLICATION <br /> kNon-Transferable,Revocable, and Suspendable <br /> -ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> AppIicatio reb�j r)lade ca n bu ss in t j10IIi onal area of the Sa oaqui ocal Health District <br /> Business Na BAj- ( Address ra - <br /> f a Owner' dress <br /> 4, <br /> .Firm Partners, Addresses and Telephone Numbers <br /> }a Business Telephone No; Emergency Telephone No <br /> Contractor Licence No. <br /> I L Applicants Name (Print) Title � <br /> e <br /> Please ch11ec�k App'licabl'e Cafe`ory(1-7)and Fill in the equfred I ' rmation <br /> 1. ❑ iPUMPE VEH P LE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For yfuly 1, .Jtirie 3�03�'~--` `-=r .2� g Disposal Sites <br /> Description(Makea ,,Colc f)k _ !Z. <br /> l Serial:No. " } �`"f �' CAL. License No. <br /> CAL. License Renewal No. <br /> Capasrity Gal.,Weights&Measures No. - <br /> Equipment Parking Address VX <br /> 2. ❑.PUMPER YARD <br /> For JUIy 1,T_ June 30, 19 <br /> No.of Vehicles Stored <br /> No, 01,Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S.bf,'R.C.E. Name R.S. or R.C.E. No, <br /> Test Location Test Date/Time <br /> !4. ❑ SANITATION PERM <br /> I ` <br /> Job Addr ss ocation <br /> /�� <br /> IOW ` Addre:SEEPAGE-PIT <br /> S PT1C TANK ❑ CESSPOOL LEACHING FIELD ❑ PACKAGE PLANT t ` <br /> ek;-ERMANENT ❑ TEMPORARY ®/NEW ❑ REPA ❑ OTHER <br /> .5. -PfCHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type,.Contruction Disposal Site <br /> No.of Units Equipment Storage/Cleaning Location(s) I <br /> 6. PACKAGE TREATMENT PLANT For July 1,-June 30, 19 f. - <br /> Operator Name Where Certified i <br /> ,Plant Location <br /> 'Plaut Capacity No. Units Served <br /> ,7. -,❑ LAUNDRY For July 1,-June 30, 19 r <br /> 'SIZE: ❑ Less Than 1,000 Sq. Ft„ ❑ More Than 1,000 Sq. Ft. <br /> ❑,DRY CLEANING, Chemicals Used/Amount/Mo. <br /> a Y - <br /> i- <br /> ! I hereby certify that I have prepared thi application and that the work will be done in acc r nce ith San Joa - i County <br /> i ordinances, state laws, and rules a lations of the San J Local Health District. ] <br /> :d 1/ <br /> :APPLICANT'S SIGNATURE X <br /> i a <br /> _.......FOR-97ARTJNEN.T-USE.O <br /> Fee4s Due,-11-.AN.NUALLX I��i�'SiTH �p,EACH ❑ January 1° Received By January 31 ❑ July.I 8 Received By July 31; . <br /> t <br /> BILLING REMITTANCE REMIT <br /> BASE: EXPLANATION $ AMOUNTDUE <br /> CHECKED <br /> ��I { / DATE DATE REMITTED AMOUNT' <br /> FEE Tr cS fS <br /> LESS <br /> ( T ORATION <br /> s <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> } V _^ � �- <br /> Received 6y Date Receipt No. Permit No. 1"yancifbate Mailed Delivered . <br /> APPLICANT RETURN ALL COPIES'TOf ENVIRONMENTAL HEALTH PERMIT/SERVICES' - 1601 E.HAZELTON AVE.,P.O.Sox 3009 .STOCKTON,CA 95201 <br />