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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheAppI ion. I - I <br /> APPLICATION ��I/ I <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAG <br /> LIQUID WASTE -. <br /> Appiicati0A�is h reby to car n b 1 ess in the jurisdictional area of the Sa Doaqui ` ath Distrix <br /> H Business a (DBA)�:/IYI Addre s <br /> Address <br /> z Owner ` I i �`'�^ <br /> J Firm Partners, Addresseand Telephone Nufmbers <br /> Business Telephone Not'200 36 - �-� Emergency Telephone No. <br /> Contractor Licence No. �_ <br /> Applicants Name (Print)r y f Title �L1)��� Date f S/' "3s <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 CO <br /> Description(Make/Yr., Color) <br /> 1 <br /> Serial No. CAL. License No. CAL. Licc Ise Renewal No. <br /> k <br /> Capacity Gal., Weights & Measures No. ] <br /> Equipment Parking Address 7 <br /> 1 <br /> 2. ❑ PUMPER YARD <br /> For July 1, Jurie 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 /> s Test Date/ ime <br /> Test Location - i <br /> } <br /> 4. ❑ SANITATION PERMIT � <br /> Jab Address/ cation co <br /> Owner Address _ f 1` <br /> 15 SS DTIC TANK ❑ CESSPOOL ©-CEACHING FIELD �EEPAGE PIT ❑ PACKAGE PLAN f <br /> L'S PERMANENT ❑ TEMPORARY E F-KEW ❑ REPAIR ❑ OTHER 1 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 y j <br /> Type Construction Disposal Site , <br /> No, of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <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. <br /> E7 DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have red this plication and that the work will be done in acccr4YwthSan Joaquin County <br /> ordinances, state laws, r r sand re the San Joaquin Local Health District. �� <br /> / r <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is <br /> Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ Janu ry rj t fed By January 31 ❑ Suly 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANC / $ AMOUNT DUE CHECKED <br /> - DATE DAT REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ,>f <br /> i OTHER <br /> f` OTHER ' <br /> G�9 <br /> Received by Date Receipt No. Permit No lssuance Date .Mailed Delivered <br /> ..APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />