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APPLICATION <br /> (For Non-Transferable, !'evocable, and Suspendable) SEPTAr <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application .s h by made to carry`}��business n the jurisdictional area oft San oaquln Local 'Health Districts I <br /> y Business Name (DBA) <br /> Application <br /> ) 8 1t!]It1s- 1 _ Address i��- �s � S' �4��s�•-O� <br /> z_Owner Address <br /> Firm Partners. Addresses and TelepFgne Num e`f_s r� <br /> e Business Telephone No. UJB/ Emergency Telephone No. <br /> Contractor Licence No. _ <br /> Applicants Name (Print) Title L`S� Date <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 /> 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 ocation Test Date/Time <br /> 4. SANITATION PERMIT r // ---- <br /> Job AddrLocation � w. <br /> �� <br /> O /wner G�y� der . / ,Lnzz< Address ' <br /> -' $ySEPTIC TANK ❑ CESSPOOL LEACHING FIELD 0 SEEPAGE PIT ❑ PACKAGE PL NT <br /> 14 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 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 /> C <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 d <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. n <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. a <br /> t <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County t <br /> ordinances, state laws, and�ru and regul tions of a an Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X <br /> \91r 002. <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 d Received By January 31 ❑ July 1 b Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> ' BASE <br /> EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> / AMOUNT <br /> FEE , / /Z <br /> LESS <br /> PRORATION •I �,(,iG' / <br /> PLUS /n <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received 6y Dale Receipt No. Permit No. Issue a at Marled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SEAVICE3 1801 E.HAZELTON, Bo:4009 STOCKTON,CA 95201 <br />