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Applications Will Be Processed When Submitted ProperlyCompleted. BeSure iosign 1nePtppucauun- <br /> APPLICATION <br /> k Mr (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> ` Application is by m o rry bus' ss in th jurisdictional area of the San Joaqu•VJ L a eal ri <br /> U) Business Name {DB Address <br /> ' z Owner Address 4645 14ildretblane <br /> Firm Partners, Addresses and T I phone bers <br /> a - Emergency Telephone No. 957-4097 <br /> a Business Telephone No. <br /> 3 Contractor Licence No. 171 <br /> Applicants Name (Print) Title flurnar - flats <br /> Please check Applicable Category (1-7)and Fill in the Required niormation <br /> 1. E] PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 4, r % Y <br /> ` For July 1, June 30, 19 - wbisposal Sites <br /> y <br /> + Description(Make/Yr., Color) <br /> Serial No. CAL�Lice`nse No. CAL. License Renewal No. <br /> ( Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address ► - - <br /> 2. ❑ PUMPER YARD E <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> f R.S.or R.G.E. No. � <br /> R.S. or R.C.E. Name 0 <br /> f^ Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Locatio _ >�3 <br /> f <br /> Owner Address <br /> SEPTIC TANK � CESPOOL LEACHING FIELD SEEPAGE PIT PACKAGE PLANT <br /> c <br /> PERMANENT ❑"TEMPORARY EW ❑ REPAIR ❑ OTHER <br /> -5. CHEMICAL TOILETS For July 1, -Jun 30,'19 i <br /> Type Construction ` Disposal Site t <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1i- June 30, 19 j <br /> 3 Where Certified <br /> Operator Name Y <br /> Plant Location <br /> Plant Capacity # No. Units Served ` <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 t <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. f <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ` to <br /> hereby c<� <br /> I jl hereby certify th t I prepared this appllc and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, n r n ulatio of th San Joaquin Lo al He District. <br /> APPLICANT'S SIGNATURE X <br /> r <br /> FOR DEPARTMENT USE ONLY' <br /> Fee Is DLLB:'❑ ANNUALLY Il PER UNIT ❑ PER SITE El EACH El January January Received By January 31 El July i &Received By July.31 <br /> I <br /> REMIT <br /> BASE �-EXPLANATII N BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> r � <br /> FEE <br /> i y <br /> LESS"' <br /> PRORATION l <br /> PLUS <br /> PENALTY �- <br /> OTHER, � <br /> - <br /> OTHER <br /> -C.00Fi lu a <br /> � /7(7q <br /> Received by" .. Date Receipt Na Permit No. Issuance Date Mail -red <br /> s Deliv <br /> RET <br /> RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH.PERMITISERVICES. 1601 E.HAZELTON AVE.,P.O.Boz 2009- STOC%TON,CA 85201 , <br /> APPLICANT— < <br /> 1 " <br /> Y .. <br />