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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ��� <br /> 'APPLICATION Lcf <br /> ( on-Transferable, Revocable,and Suspendablt <br /> VIRONMENTAL HEALTH PERMIT 1 SEPTAGE <br /> LIQUID WASTE I / <br /> Application is h reby made to carry on byJJ,siness in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name (DBA + I(C Edi ICT—Y w .Yi/ <br /> 1e ) )_ir-4� Address 7 T.,-� �' „5... Q <br /> Owner, _ l_/�C•�7e Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> 'n Business Telephone No. - '�� `? Emergency Telephone No. <br /> Contractor Licence No. <br /> �Applicants Name (Isrini). fd� F/_/2 title-' Date <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 w <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. _ CAL. License Renewal No. <br /> Capacity Gel.,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 /> Test Location 'Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> O�wn - �; Si Addressl �� <br /> LAYSEPTIC TANPOOL ACHING FIELD 0 SEEPAGE PIT ❑ PACKAGE PLANT f <br /> 1] PERMANENT ❑ TEMPORARYP,NEW 0 REPAIR ❑ OTHER <br /> 5. 0 CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site ' <br /> No.of Units Equipment Storage/Cleaning Location(s) r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ' <br /> c <br /> Operator Name Where Certified <br /> Plant Location _ <br /> Plant Capacity -- —.No. Units Seryed _ <br /> 7. ❑ LAUNDRY For July 1, -June 30. 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., Q More Than 1,000 Sq. Ft. <br /> [?'DRY CLEANING, Chemicals Used/Aniount/Mo: T.. <br /> I hereby certify that I have Prepared this application and that the work will be done in accordance with San Joaquin County -471 <br /> ordinances,state laws, and rules end re Ietlons of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X � �-�--, <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BILLING MITTANCE S <br /> BASE EXPLANATIONBILLING <br /> DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE N <br /> LESS Uri <br /> U <br /> PRORATION <br /> PLUS <br /> PENALTY ) i� <br /> OTHER <br /> OTHER <br /> �� 75 S I� •�-/3�/ <br /> Received by Date Raceept No. Permit No. lisuancofDatt Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Eos 2009 STOCKTON,CA 25201 <br />