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NpPIcauons rrui oe rrocexseo viten auomuteo rropeny%.ompleieo. oe oure i o aign I ne Appucauon. <br /> .` <br /> APPLICATION ] <br /> r Non-Transferable, Revocable,and Suspendab:' l <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicationis reby made to carry on business in the jur dictional area of the San Joaquin Local Health Di Frict <br /> rn Business Name A} Address <br /> z Owner Addresses--�-�— <br /> 4 <br /> J-Firm Partners, Addresses and Telephone Numbe Cao <br /> Do' Business Telephone No. S-1 a r-______ - Emergency Telephone No. <br /> -Contractor Licence No. 2_. - <br /> Applicants Name (Print} Title. Date -fid <br /> k` Please check Applicable Category(1-7)and Fill in the RequirA Information <br /> E 1. ❑ PUMP-ER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> I For July 1, June 30, i9 Disposal Sites <br /> r <br /> 4 Description,(Make/Yr.,Color,}. . <br /> r ,.. �.. <br /> Serial,No. ' CAL. License No. CAL. License Renewal No. <br /> Capacity" Gal., Weights &Measures No. <br /> Equipment'Parking Address% f n <br /> 2-. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles„Stored ^1 <br /> No. of Chemical°Toilets St6red <br /> 3. ❑ PERCOLATIONaTE6 <br /> G <br /> R.S. or R C.E. Name R.S.or R.C.E. NO. <br /> Test L�Fcation Test Date/Time J <br /> 4. SANITATION PERMIT E <br /> Job Address/Location <br /> Owper Address �¢ <br /> L�PTiC TANK 11 CESSPOOL LEACHING FIELD C� Y Z@I-PAGKAGE'*PLANT �----: <br /> L`s PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER f <br /> N <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 0 "' �' <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..C.erlified--------� <br /> Plant Location i <br /> Plant Capacity No, Units Served f <br /> 7. 11 LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. s .vim ..,V.,. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ! 1 <br /> 1 hereby certify that I have prepared this application and.that the work will be done in ajc0rdance with San Joaquin County <br /> ordinances, state laws, and rules and ulations of the San Joaquin Local Health Distri�. r <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT ULY <br /> Fee Is Due: ❑ ANNUALLY - © PER UNIT ❑ PER SITE ❑ EACH 4VXruary 1 &Received By January 31 ❑ July.1 &Received By Judy 31 <br /> REMIT <br /> BILLING TANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> / AMOUNT" <br /> FEE Lj S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. 1.1ssuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE:,P.O.Box 209 STOCKTON,CA95201 <br />