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APPLICATION <br /> Pn(For Non-Transferable, Revocable,and Suspen i?)' ENVIRONMENTAL HEALTH PERM I IT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) Address <br /> Owner S <br /> k' Addres J1 6f')0 <br /> Firm Partners,Addresses and Telephone Numbers <br /> Business Telephone No, <br /> Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) <br /> C7i f TitleDate P)l <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. 11 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 Pairlin, Address cue <br /> 2. 0 PUMPER YARD <br /> For July 1,_ June 30, 19 <br /> No. of Vehicles Stored <br /> No.of Chemical Toilets Stored <br /> 3. 11 PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or S,C.E'No. <br /> Test Location <br /> Test Date/Time <br /> 4. 0 SANITATION PERMIT <br /> Job Address/Location-- p,' <br /> Owner 1A.. (Tr„,, ,r• l <br /> Fi TXSEPTIC TANK 11 CESSPOOL LEACHING FIELD C1 SEEPAGE PIT EI PACKAGE PLANT <br /> UKERMANENT 0 TEMPORARY 11 NEW 11 REPAIR 0 OTHER <br /> 5. C1 CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction — Disposal Site <br /> No. of Units _ Equipment Storage/Cleaning Location(s) <br /> 6. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name <br /> Where Certified <br /> Plant Location <br /> Plant Capacity <br /> No. Units Served <br /> 7. C1 LAUNDRY For July 1. -June 30, 19— <br /> SIZE: 0 Less Than 1,600 Sq. Ft., 0 More Than 1,000 Sq. Ft. <br /> ;, ❑ DRY CLEANING, Chemicats Used/Amount/Mo, <br /> Flnt,trnwno.orfir.;:nsrad <br /> i11 Sur;l! n C0.4,Win�"t 11!.'foll o'f.'t.-g <br /> tiarineras to to wor, I[A].Lk� jil <br /> lip t le�_ <br /> Contra '9 iE P"Mp!nw <br /> r, sub -ontractin <br /> enlr.�Cy per., <br /> to V'(Irtl-:�'ri's�")p' � 1 <br /> I !�Jli <br /> )&� �0. <br /> I hereby certify that I have prep ed this application and that the Vprk Will be done in accordance with San Joaquin Count <br /> ordinances, state laws,and;�yd re ions of the an Joe 0 Health District. <br /> F, APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 0 ANNUALLY ❑ PER UNIT ❑ PER SITE 1:3 EACH ❑ January 1 &Received By January 31 ❑ July I d Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE REMITTED AMOUNT DUE CHECKED <br /> DATE <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY 7 2 --S_} <br /> 01 HL11 <br /> OTHER <br /> dved y aRecet No Permit No.. Issuance ate Mailed— livered <br /> F1 ate ipAPPLI ANT—RETURN ALL COPIES TomENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZIELTON AVE.,P.O.Box 2009 STOCKTON,CA 95 <br />