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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ,..ror Non-Transferable, Revocable,and Suspendaet15) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicati I re ma a to car og��u�slr1�s�in the' risdictional area of the SaP oa ui cal.id Ith Distrl�c�►t <br /> Business N, (DBA) i�by m y, carry I ISA 0- fJc'r Address / V � z'I �p.v ' `0, <br /> : Owner 'rfh CAAGf/E Address <br /> Firm Partners, Addresses andIgp hone Numbers <br /> Business Telephone No. 1 3- Emergency Telephone No. <br /> Contractor Licence No. y3 <br /> Applicants Name (Print) '—Ti M CA0,C,I Ie Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licznse 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 /> i <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT �f <br /> Job Address/Location °� � �"'�y 2tJ ' ` ipL,,; C� <br /> Owner Wil IA61 L^tiTki/y Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW C1 REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 f��L.L' <br /> Type Construction Disposal Site A�� '1 T% n <br /> No. of Units Equipment Storage/Cleaning Location(s) 4)ql rtiq SUMP <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 C <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> m` <br /> CS <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, an ules and regulations of the Sa7,Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X �� ' ` Cc/) �ocL 0�1 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION <br /> BILLING REMITTANCE $ <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE QS 4� *L S <br /> LESS IJ <br /> PRORATION <br /> tj <br /> PLUS (n <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 9D <br /> Received by Date Receipt No. Permit No. Issuan a Date ed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />