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Applications-Will Be Processed When Submitted Properly Completed. Be Sure To Si n The Application. <br /> APPLICATION r <br /> f (For Non-Transferable, Revocable, and Suspendabla) <br /> r <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> r LIQUID WASTE <br /> ApplicaqT is hereby made to car n busines p the jurisdictional area of the San Joaquin oc ealth D' trio <br /> .F. Business Name (DBAr f'f�!`-1 �f f AD Addres <br /> xzej <br /> aOwner Address - +! <br /> J Firm Partners, Addresses and elephone Numbers �. <br /> a Business Telephone No <br /> ness eepo . Emergency Telephone No. <br /> � � J <br /> Contractor Licence No. <br /> Applicants Name (Print) Title5�� Date r <br /> Please check Applicable Category (1-7)and Fill in the Required Information. L_ <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. Liccase Renewal No. <br /> Capacity -- GaI,, Weights-&Measures No. <br /> Equipment Parking Address L. - i # <br /> 2. 11 PUMPERYARD <br /> For July 1, June 30, 19 <br /> No. of.Vehicles Stored <br /> t I <br /> No. of Chemical Toilets Stored eI <br /> i❑ PERCOLATION TEST -1. r"-'3. "t <br /> R.S'or R.C.E. Name' R.S.or,R.C.E. No. <br /> Test„Date/Time'” <br /> Test Location <br /> Location <br /> i 4. ® SANITATION PER T <br /> k Job Addres/s6ocatiornOwner „�� <br /> lTi�. �f=,G►f f� I •X `R Address n, ; <br /> ❑ SEPTIC TANK CESSPOOL ❑..LEACHING FIELD 11SEEPAGE PIT 11 PACKAGE PLANT <br /> r% El ❑ OTHER <br /> ❑ PERMANENT ❑TEMPORARY -1❑ NEWN�, } <br /> 5. ❑ CHEMICAL TOILETS;,P,For July 1, -IJune 30, l9 <br /> Type Construction . ; t _ ,-- Disposal Site <br /> No. of Units x _j Equipment Storage/Cleaning-Locations) f <br /> ” } <br /> 6. 13 PACKAGE TREATMENT PLANT For.July,1, -June 30, 19 f <br /> Operator Name ~" Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30,19 <br /> I SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. t <br /> t ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that thew rk will be`done in ccordance with San Joaquin:County i <br /> ordinances, state laws, an les an regulaf he a ui ocal Health Di i <br /> APPLICANTS SIGNATU <br /> FOR DEPARTME USE ONLY s = <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT n ❑ PER SITE IS EAC ❑"January 1 &Received By January 3.1 tea.❑July 1 &Received By Jury 31 <br /> REMIT <br /> BILLING <br /> "t BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> IFa <br /> LESS <br /> PRORATION <br /> PLUS rt, t "'�!"'• .•�.n.- .-..+.. <br /> PENALTY <br /> [ OTHER <br /> fi OTHEH <br /> . �1q•-- 6g� � f. <br /> Received by Date , - Receipt No. Permit No. I uan Date Mailed eliver d -CA 952171,'yr,'' <br /> 1� <br /> APPLICANT—RETURN ALL COPIES TOC F ENVIRONMENTAL AEALTH PERMIT/SERVICES - 1601 E.HAZELTON AYE.,P.O.Boz 2009. STOCKTON, i' <br />