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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. P <br /> ` "'` APPLICATION I <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE ` <br /> Applicatio s�heb <br /> 1p�to ca on b sess in the jurisdictional area of the ,Joa n LocZ-001__al Health Di Ict { <br /> Business (DBA) �s� Addre �' t! <br /> z Owner t `r Address.l_{s�p�/ �( e� ' c <br /> Li a v <br /> Firm Partners, Addresses and Tele h2on�e,Ntu bersCC <br /> Business Telephone No �3h ,3f..� --- Emergency Telephone No i <br /> Contractor Licence No. t/ 7 l <br /> — —.-- — — <br /> j Applicants Name <br /> IP <br /> Title �1GJN[. Date z_' <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,Uceme Renewal No. <br /> _ <br /> Capacity — _ Gal.,Weights & Measures No. <br /> Equipment Parking Address_ <br /> 2. ❑ PUMPER YARD _ —For July 1._ June 30. 19 <br /> No of Vehicles Stored 1 <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 <br /> �,Location Test Date/Time <br /> 4. LT SANITATION PERMIT <br /> Job Address.L cation l�1147� ND ,`pew ' <br /> ,0 'er _ �� � Address ���Z� � ` t <br /> v SEPTIC TANK CESSPOOL U LEACHING FIELD 4;-`EEPAGE PIT PACKAGE PLANT <br /> 'PERMANENT OTEMPORARY D'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 /> F" <br /> 6. ❑ PACKAGE TREATMENT PLANT For July i, -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, f9 <br /> SIZE ❑ Less Than 1.000 Sq Ft, ❑ More Than 1,000 Sq Ft <br /> ❑ DRY CLEANING. Chemicals Used/Amount/Mo <br /> 1 <br /> I hereby certify that I have pr d this appllc n -nd that the work will be done in acro a with San Joaquin County <br /> ordinances, state laws, a ula nd re( ula for o e n Joaquin Local Health District <br /> APPLICANTS SIGNATURE X - _._ <br /> FOR DEPARTMENT USE ONLY <br /> Fee 16 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SI 11: ❑ FACH _❑ Janua• eC ived By January 31 ❑July 1 d Rrcrived By July 31 <br /> DIlI1NG HEM TAN REMIT <br /> BASE EXPLANATION DATE D T REM TTED AMOUNT DUE CHECKFD <br /> AMOUNT <br /> FEE <br /> 1 <br /> LESS � — <br /> PRORA r ION <br /> PL Ub <br /> PENAL TV '� _ "'"""^" • l <br /> U1HER --- <br /> i <br /> dived by Data Receipt No Permit No ----- — Issuance Dare Mailed--- Delivered - --— - <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 IL HAZELTON AVE.,.PO-Box 2009 STOCKTON,CA 95201 <br />