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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. J. <br /> ' APPLICATION <br /> (For Non-Transferable;Revocable,-and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH,PERMIT <br /> UID WASTE <br /> LI�4+1 %`(Ar <br /> ©d7-�GY z -O <br /> Application is hereby made to carry on business in the j4r sdictional area of the San Joaquin Local Health District. <br /> y Business Name (DBA) D�C?' �N�'�� i s ( �. -Address ___��yl0 A �r V �I✓� , SID <br /> a Owner C. C1i&WC W0NCr Address. <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness.Telephone No. 64'.°! `�.-- Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name(Print) G= eHftNCf- _W CG., Title pgzls• Date <br /> - p i <br /> Please check Applicable Category,(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r <br /> For July 1, June 30, 19 =- •-_- Disposal Sites <br /> Description(Make/Yr., Color) j <br /> Serial No. CAL. License No. CAL. License Renewal No. ..1� <br /> Capacity Gal.,Weights &'Measures No. <br /> Equipment Parking Address I� j <br /> 2. ❑ PUMPER YARD 1 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored j. <br /> No. of Chemical Toilets Stored I <br /> I ! <br /> 3. X PERCOLATION TEST 11 ti <br /> R.S. or R.C.E. Name C hWC,F_ VJy W G' R.S. or R.C.E. No. ?-J+ Cd i �--L G <br /> Test Location IS, r--14D LIIkCYO R4O F=-OIND Test Date/Time '.1 +W <br /> 4. C1 SANITATION PERMIT E+RtiTI I�Cr� Pri�1- �S SU 1!lD w t S w 1v ""� —' f <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER !{ <br /> � I <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 } <br /> Type Construction f Disposal Site 3 <br /> No. of Units Equipment Storage/Cleaning Location(s) I <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -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, 19 <br /> 9 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. I <br /> I hereby certify that I have prepared this application and that th will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and re I San Joe i I Health District. <br /> 'APPLICANT'S SIGNATUREX } <br /> ' FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACHr ❑ January 1 &Received By'January 31 ❑ July 1 &Received By July 31 <br /> i <br /> - BILLING REMITTANCE $ REMIT <br /> BASE � EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> ' <br /> AMOUNT'- <br /> FEE <br /> MOUNT'- <br /> al <br /> FEE - - <br /> LESS <br /> PRORATION <br /> PLUS I <br /> PENALTY j <br /> ~*OTHER <br /> OTHER. <br /> P- <br /> I Received by Date Receipt No. Permit No. Issuance Date M tl Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O-Box 2,009 STOCKTON,CA 95201 <br />