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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> - " (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of th an Joaquin Local Health District y <br /> rBusiness Name (DBA) t�t1} IC1G Address9, d <br /> a Owner Address <br /> J Firm Partners, Addresses and hone Numbers <br /> aBusiness Telephone No. 'C�� "���7 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) �'T1Si��t �. `�4�'l S Title Date 3e <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. License Renewal No. <br /> Capacity Gat., 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 /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or,R.C.E, No. <br /> Test6Locc n Test Date/Time �y <br /> 4. I� SANITATION PERMIT lv <br /> Job Address(Location <br /> -Z 0G LAtAA}&SVC-5 <br /> Owner oLE Address dl <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ErSEEPAGE PIT ❑ PACKAGE PLANT �> Q <br /> 211PERMANENT [] TEMPORARY ❑ NEW 9-VEPAIR ❑ OTHER ' <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 !a <br /> k Type Construction -_ Disposal Site <br /> -.—��b: - —�_�_ ,..:. a.nr4�F•s"yf•Yir-.4•�,Yr.ve'-.-.M,.+ <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 /> H <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑. Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. f. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. } <br /> I hereby certify that I hprepared this applic ' na�thhe work will be done in accordance with San Joaquin County <br /> ordinances, state laws n gulation of he quinji-ocal Health District, <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> 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 <br /> r <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER <br /> Received by Date Receipt No OPermiNo. "� IssUenee DDate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES Tdi ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTbN A oz 2009 STOCKTON,CA 95201 <br /> 7--7—frac r <br />