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APPLICATION <br /> ("f Non-Transferable, Revocable, and Suspendabler/ <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> ... Application is ereby�made to c rry n businesss�in the r�sdi tonal area of the San Joa uin Local Health Distljgtt <br /> FBusiness Name DBA) Addressd�'' <br /> Owner Address <br /> Y <br /> `• =irm Partners, Addresses and Tele one Nu ers <br /> Q'Business Telephone No. S _ Emergency Telephone No. <br /> Contractor Licence No. <br /> applicants Name (Print) Title — Date �oZ' <br /> , ?lease check Applicable Category (1-7) and Fill in the Required nformation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> 'or 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 C1--PUMPER YARD <br /> For July 1, -Jur1e.30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Ired <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test L�tion Test Date/Time <br /> 4. 9 SANITATION PERMIT <br /> Job Addces KI-ocation G e e <br /> Owrr LTJ Address <br /> r .,/ <br /> LTIC TANK ❑ CESSPOOL LEACHING FIELD O SEEPAGE PIT ❑ PACKAGE PLANT <br /> U PERMANENT ❑ TEMPORARY ❑ NEW PAIR ❑ 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 /> 7. ❑ LAUNDRY For July 1, -June 30, 19 f' <br /> SIZE: 11 Less Than 1,000 Sq. Ft., 13 More Than 1,000 Sq. Ft:" <br /> a❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> e <br /> I hereby certify that I have preps ed this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 7 A <br /> -* <br /> FOR DEPARTMENT USE ON <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACHJanu ec ived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMIT E $ <br /> BASE EXPLANATION DATE D REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> p �d <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r <br /> OTHER r 7 ` <br /> !'e FtL <br /> Received by Date Receipt No. 1 Permit No. Iss n e pate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />