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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> d (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE # <br /> -Application her y made to fry on u iness in the jurisdictional area of the San Joaquin Loc I Pealth District( r}�/� <br /> FBusiness Name (bBA a %ddress :57"T`4V),/10Win LCA 1 11 <br /> z Owner Address _. <br /> C <br /> Firm Partners, Addresses and T�elle_pho a Numbers &' ` <br /> M <br /> Business Telephone No. }��� a-1!9� _ Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants,Name (Print) �• Title 9IS -e Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Q,y <br /> For July 1,^ June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License N67 CAL. License Renewal No. <br /> p. <br /> �s x 's 4. <br /> Capacity,_ Gal-,_Weights &_MeasuresNo:, ..__ _ _R 1s1, �` <br /> Equipment Parking Address <br /> 2. ❑ MPE <br /> PUR YARD-'i. � <br /> For July 1, June 30, 19 r r <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets-Stored <br /> 3. ❑ PERCOLATION TEST <br /> 1 f <br /> R.S or R.C.E. N me �)' R.S. or R.C.E. No. <br /> Tes Location = " Al. <br /> eTest Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location d v M * �s <br /> Own11er C �' ,Address 4 ~ <br /> 'SEPTIC TANK <br /> 13 CESSPOOL LEACHING FIELD E] SEEPAGE PIT, ❑ PACKAGE PLANT C r 1 t <br /> PERMANENT TEMPORARY KNEW " ' -❑ REPAIR ❑-OTHER ' k. 1 ! ! r <br /> 5. CHEMICAL TOILETS For July 1, -June 30, 19 "n"F �A, 0 <br /> Type Construction Disposal Site _ - r •1 <br /> NoR of Units Equipment Storage/Cleaning Location(s) _ �'t �3 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19- 1 <br /> Operator NameF Where Certified <br /> Plant Location '" z <br /> r I <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 s i <br /> SITE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> 0-'DRY CLEANING, Chemicals Used/Amount/Mo. ""� <br /> .v ...:~ i <br /> \4 <br /> ' I hereby cent fyrthat l-have prep' d this a, lil ation-and that the work will be done in accordance with San Joaquin:County i 3 <br /> ordinances, state laws, and rul nd r t7lations of 6-San Joa `in -ocal Health District. f <br /> APPLICANT'S SIGNATURE X _ a <br /> II FOR DEPARTMENT USE ONLY i <br /> - Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑-PER SITE ❑ EACH ❑ January 1 &'Received By January 31 ❑ July 1 &Received By July 31 <br /> t <br /> REMIT 3 <br /> BILLING REMITTANCE $ ' <br /> BASE EXPLANATION `�� AMOUNT DUE :CHECKED <br /> �".."s'�"""'..,� .DATE-�.x.-.�».�+-..DPiTE' —REMIT-TED ....a-.�.�:w,,,•,.w.w.AMOUNT <br /> ov <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS We, y/� n 16-vi— <br /> PENALTY <br /> r ; <br /> f PENALTY I f "Ir <br /> OTHER <br /> OTHER 'rw Y t!C! <br /> f L df 0Y <br /> rC-13Received by Date - Receipt No. Permit No- issuaMailed Delivered ; <br /> APPLICANT—RETURN ALL COPIES TO:. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..;PLO.Box-2009 STOCKTON,CA 95201 _ <br />