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Applications Will Be Processed When Submitted Properly Completed. Be sure To Sign The Application. <br /> APPLICATION <br /> (For Nan-Transferable, Revbdable, and Suspendable) <br /> y _ ENVIRO�NMKNTAL HEALTH PERMIT SEPTAGE <br /> - -- 091.110 wasrE' + , ..,q.� ` <br /> Application is eby made to c l 7 /�} = ASO .•- <br /> ry on b • ess in the jurisdictional area oft uin L I th D t f <br /> ,F Business Name (DBA) <br /> aOwner Address �. y� <br /> Address <br /> Firm Partners, Addresses and kh-mbers <br /> I Business Telephone No. ti <br /> e % Emergency Telephone No. <br /> Contractor Licence No. -- <br /> `�L Applicants Name (Print) r <br /> Please check Applicable Category (1-7)and Fill in.the Required Information Title Date. <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ' <br /> For July 1,- I .-June 30,.19 Disposal Sites <br /> Description(Make/Yr., Color) �! <br /> - i <br /> Serial No. CAL. License No. <br /> Capacity Gal., Weights R Measures No. CAL. License Renewal No. <br /> Equipment Parking Address ; <br /> 2. ❑ PUMPER YARD r' <br /> For Jul 1 <br /> Y June 30, 19 <br /> No. of Vehicles Stored } : •") <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST r <br /> R.S. or R.C.E. Name <br /> R.S. or R.C.E. No. <br /> Test Location c <br /> '4• 11 SANITATION PERI�iJ Test Date/Time ` <br /> Job Address/Locatio (�., ll��-- ,G 14 z-5--i7p (,21 <br /> Owner D/1� Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL K LEACHING FIELD11ir SEEPAGE PIT ❑ PACKAGE PLANT k <br /> `❑ PERMANENT ❑ TEMPORARY ❑ NEW <br /> 5• ❑`CHEMICAL TOILETS For July 1, -June 30, 19 REPAIR ❑ OTHER <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 /> Operator Name <br /> Plant Location Where Certified <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,.-June 30, 19 k - , .,, i <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Thar�1,0b0-Sq" Ft.-'.. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - I <br /> c,+rmgrorlicensed ngorit'ss!g"A*14reIII TIr'0;icw5:ta:"Icc.Wi lthat inth^pe.fDmnarcaofthawork,for}rf,ichthis permit isissued,irl;ailnot crnpfo,11yper�, <br /> i rE°.,i;:er a5 t0 tlei•0+8 'r4 rh r'2il�0ffli8.-� <br /> 0act3r's hirino or a e y¢:a 1 h ,-c _ <br /> +„D1 persms subject i0 V Gri�Ei j'1`3�p iiN ;;,y*,;' 1, y�! jF '`yf�i irs�., 1 cErfliPhat in the perfc:irarco c t:,c LYCrk for M-ich 1i',i5 permit.5 issued.I.3ha!i r <br /> I hereby certify that 1 haver prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r es and regulations f the San uin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> �(S <br /> ( FOR DEPARTMENT,USE ONLY- <br /> r' Fee Is Due: ❑ ANNUALLY PER-UNIT <br /> '❑.PER SITE` ❑ EACH ❑ January 1 A Received BY Januar <br /> r Y 31 <br /> ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING ' R�AITTANCE $ REMIT <br /> a DATE. REMITTED DATE- AMOUNT DUE CHECKED <br /> _ . <br /> FEEr AMOUNT <br /> LESS <br /> PRORATION _-� _ �• _ <br /> PLUS { f - <br /> PENALTY y <br /> s <br /> OTHER <br /> OTHER ~+ 1p <br /> ` �s 1 � � <br /> Received by Date Receipt <br /> APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES Issu nee Q e Mailed Delivered �r <br /> 1601 E”HAZE'TON AVE.,P.O.Box 2009 STOCKTON,CA 95201- <br />