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Applications Will Be Processed When Submitted Properly Completed.`Be Sure To Sign The Application. <br /> APPLICATION. <br /> iRevpe,'and Suspendable} SEPTAG[ <br /> [rwr Nell-Tianslera6le, Cabl <br /> ENVIRONMENTAL t1EA1-TH P�ftMLT-- <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of theJoaquin�ocaLHealth District <br /> �,� a �� � Address <br /> HBusiness Name (DBA) Address <br /> a Owner <br /> Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. °4 <br /> aBusiness TA No. <br /> Contractor Licence No. �' �' /r.,/rte Date—.� -- <br /> Title N <br /> Applicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill to the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July-1, 'June 30; 19 -' E# <br /> Disposal Sites N <br /> _. <br /> Description(Make/Yr,Color) , CAL. License No. CAL. License Renewal No. T <br /> Serial No. <br /> Capacity Gal.,Weights &Measures No. 1- <br /> Equipment Parking Address }. <br /> 2. ❑2 PUMPER YARD <br /> For July 1, June 30, 19• - <br /> No. of Vehicles Stored <br /> L <br /> No. of Chemical Toilets Stored <br /> g, ❑ PERCOLATION TEST R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> 4. g SANITATION PERMIT _ <br /> Job Address/Location <br /> pEe1lL�l Address LJ PACKAGE PLANT <br /> Owner, ❑'LEACHING FIELD ❑ SEEPAGE PIT _ <br /> SEPTIC TANK' El CESSPOOL ❑ OTHER <br /> PERMANENT <br /> + ❑ TEMPORARY ❑ NEW )REPAIR . <br /> 5. ❑FCHEMICAUTOILETS For July 1, -June 30, 19 <br /> Type Construction <br /> Disposal Site <br /> .Equipment Storage/Cleaning Location(s) <br /> No. of Units <br /> g, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name ; <br /> Plant Location _ Ir No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY ' For July'1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. € h <br /> ❑ DRY CLEANING, Chemicals Used/Amount/MO. µ <br /> ' Nomeocvrarsr;ican�sdscv� rsi�n ;��r+�nr'i'irsita",alro�a.n r r r„'-`t-;'•;:;':E;^n ;u-mamCcot,"�evrcrkfor:vit:Cttthi5permiti5is5 ^d,[shall not etrtployanyp t�v <br /> in such manner as to Gscnmr�suo 1ec la <br /> ?:CiO11Lri1CtOr•S h'7111 "'l;n•t=r_ - -'- '-' .-.••�. ..i;r:.; i}l.^..:,,�iie po,',orr.janIl;L of tiie L ufk 1cr 41ii1 Cit.this p,_r rit is issued,I silall <br /> employ persons subs lL Y J:n.7J..O J"u i. d.. i1 va•..u,...u. <br /> I" I hereby certify that I have prepared this application and that <br /> aquin Local will <br /> Heaith D str ct ccordance with San Joaquin County <br /> ordinances, state laws, and rules_ and regulations of e <br /> APPLICANT'S SIGNATUREX <br /> FOR DEPARTMENT USE ONLY _ <br /> - - - ., -• <br /> i y1 <br /> , f 'ii ❑ January 1 &Received By January 31 ❑'July <br /> 1'&Received By July 31 <br /> REMIT <br /> Fee IS Due:�❑•ANNUALLY x ❑"PER�UNITf'"'-'❑'PER SITE -, ❑ EACH w <br /> >7-— ' r BILLING REMITTANCE $ AMOUNT DUE - CHECKED <br /> s BASE ;, EXPLANATIONDATEDATE REMITTED AMOUNT <br /> -,.._.. <br /> } FEE <br /> LESS <br /> PRORATION' - <br /> „ i PLUS <br /> PENALTY _ <br /> ` k � <br /> OTHER <br /> OTHER. € <br /> + 55uanC Date Mailed Delivered <br /> Received by i - Daie <br /> Receipt No. Permit No, s <br /> 4 RETURN ALL-COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES�� 1601 E.HAZELTON AVE., <br /> APPLICANT P.O.aov 2009 "5TOCKTON,CA 95201 <br />