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W __ _.� ..._... <br /> Applications Will Be Processed When Submitted Properly Comp leted. Be <br /> bure <br /> APPLICATION <br /> SEPTAGL / <br /> (For Non-Transferable, Revocable,and SusQendab a r/ <br /> ENVIRONMENTAL HEALTH,PERMIT <br /> LIQUID WASTE <br /> Application I ereby made to call on business in the jurisdictional area of# San Joaq al Health <br /> alt�istr' t ` 1 <br /> l�f $ . Address, <br /> rn Business Name (DBA) <br /> z Owner Address <br /> r _ <br /> Firm Partners,Addresses and Tele one Numbers Fco � Emergency Telephone No <br /> CL <br /> Business Telephone No. _ y <br /> Contractor Licence No. T Title Date �kzvz­" <br /> Applicants Name (Print) z t <br /> Please check Applicable Category (1-7)and Fill in the Required Information t �" <br /> 1. ❑ PUMPER VEHICLE PERMIT,REGISTRATION (FOR EACH VEHICLE) <br /> rDisposal Sites <br /> For July 1, June 30, 19 <br /> Description(Make/Yr., Color) CAL, License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity ,Gal.,Weights & Measures No. <br /> ''�^*.l "� A. <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.No. i <br /> R.S. or R.C.E. Name j T t <br /> Test Location Test Date/Time r <br /> 4. ❑ SANITATION.PER 11�� �' <br /> Q- 6 6 Cz � <br /> Job Addres ocation <br /> r CERMANE <br /> er =L7,1I.J Jill fl D j5L Address OS <br /> EPTICTA •t ❑'CESPOOL S ;LEACHING FIELD ,SEEPAGE PIT .0,PACKAGE PLANT <br /> NK <br /> ❑ '❑ OTHER t <br /> NT ❑ TEMPORARY XINEW' REPAIR <br /> 5. ❑ CHEMICAL 701LETS'�For July 1 -"June"30,'19'" -+ #� ' t' <br /> Type Construction ! Disposa`I Site . <br /> No. of UnitsI Equipment`Storage/Cleaning Locations} Ilk a <br /> g. ❑ PACKAGE TREATMENT PLANT For July l,,---June 30, 19 - <br /> ..- Where Certified <br /> Operator Name - - <br /> Plant Location + <br /> No. Units Served <br /> Plant Capacity <br /> E k <br /> 7. ❑ LAUNDRY •Fgr'July 1;-June 30, 19 ' ki <br /> SiZE: ❑ Less Than.1,000 Sq..Ft„ ❑ More Than 1,000 Sq. Ft, <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. Y_ <br /> I <br /> hereby Y certif that I have prepared this application and that the work will be done in accordarl e.with San Joaquin County <br /> ordinances, state laws, and r s and regulati ns oft n +oaq 'n Local Health District <br /> APPLICANT'S SIGNATURE X ! ► �_ <br /> W. FOR DEPARTMENT.USE ONLY .t <br /> '' <br /> Fee Is Due: 11 ANNUALLY ❑'PE19 TWIT ❑ PER SITE ❑ EACH '❑ January`t,_&Received By January 31 <br /> E] July 1 &ReceivedREMIT <br /> BILJuly 31 <br /> "r LING REMITTANCE "AMOUNT'AMOUNT DUE CHECKED <br /> t BASE (.)(PLANATION DATE .:DATE "REMITTED r AMOUNT <br /> FEEt_m <br /> LESS <br /> PRORATION <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Permit o. ssu ce Da Mailed Delivered <br /> Received by Dae a Receipt No.- _ <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> -1601 E.HAZEL N AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />