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r r'Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> _(For Non-Transferable, Revocable, and Suspendabie) <br /> sem' ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> r �= LIQUID WASTE <br /> Applicatio-a is hereby-made to carry_2onpbusiness in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name D J Address C 0_ &, CZE <br /> aOwner _ Addresses GYTsps�IyF 'SSPT1C &— <br /> u Firm Partners,Addresses and Telephone tubers <br /> J� ZAOCKIoin, Calif. <br /> CL a Business Telephone No. 4�- ���� Emergency Telephone No. r2C or S IC. e <br /> 1 Contractor Licence No. <br /> Applicants Name (Print) S Title 9 j Date 6�I <br /> Please check Applicable Category (1-7) and Fill in the Required Information y <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) oa <br /> For July 1, June 30, 19 Disposal Sites <br /> 1 <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. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> �No. of Chemical Toilets Stored <br /> t'3. ❑ PERCOLATION TEST I <br /> R.S. or R.C.E. Name R.S. or R.C.E. No, <br /> 3' <br /> Test ocation Test Date/Time <br /> 4. SANITATION PERMIT _ <br /> Job Address/Location <br /> caner Address O <br /> SEPTIC TANK CES 0, LEACHING FIELD SEEPAGE PIT El PACKAGE PLANT <br /> `'PERMANENT ❑ TEMPORARY 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 /> 6. ❑ PACKAGE TREATMENT PLANT;wFor July 1, -June 30, 19 <br /> Operator Name _ Where Certified C <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 �~ <br /> r SIZE: C3 Less Than 1,000 Sq. ft., 13 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> { <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and les a d regulations of the San Joaquin L I Health District. CtPftEMCE S SEPTIC & SEWER SERVING <br /> APPLICANT'S SIGNATURE X Qn nr 21 Ctnr4tnn CAUL 95205 <br /> 9 Caatracta ' ic. 2fi717jr <br /> FOR DEPARTMENT USE ONLY <br /> 4 Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH © January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 'BILLING REMITTANCE $ REMIT <br /> , BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> - AMOUNT JJ <br /> FEE Y <br /> ( LESS <br /> l PRORATION <br /> IF PLUS <br /> PENALTY <br /> OTHER ` <br /> i OTHER \ <br /> Received by Date Receipt No. Permit No.. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL'COPIES TO: ENVIRONMENTAL HEALTH PERM ITISERVICES 1901 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />