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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> -� APPLICATION <br /> 4 (Far Non-Transferable, Revocable;and Suspendable) A <br /> ENVIRONMENTAL HEALTH'hERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application i ereby made to car on busine in the'ur'sdictional area of the n J aquin Loc I Healt�District <br /> wBusiness Name (DBA) -Address <br /> Owner Address f - <br /> Firm Partners, Addresses an T e hone Numbe s T <br />' a Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> LAPpIicants Na a (Pin) ' Title r Late <br /> Please check Applicable Category-(1-7)and Fill in-the Required Information s . <br /> Y:f 1-0 .PUMPER VEHICLE-PiRMIT:REGISTRATION (FOR EACH VEHICLE) " <br /> For JulyF1, June 30; 19 l Disposal Sites # <br /> Description(Make/Yr., Color) ,..4 " / f'` <br /> Serial No. CAL. License No. i } CAL„ License Renewal No. r <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address w �� <br /> 2. 0 PUMPER YARD T ----• . . ---�� _--Y.�__ - -_ ___ --..� - ... .-...r.. <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored C <br /> .3 -❑-PERCOLATION-TEST <br /> R.S.tor R.C.E. Name R.S. or R.C.E. No. <br /> Testi Location Test Date/Time i <br /> 4. SANITATION PERMIT <br /> Job Address/L cation r <br /> Owner Addre s { i 1 <br /> ❑ SCEPTIC TANK ❑ CESSPOOL rf LEACHINGFIELD f SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ <br /> PERMANENT ❑ TEMPORARY ❑'NEW t EPA IR ❑ OTHER , ' a <br /> 5. CHEMICAL TOILETS For July 1,.r June 30,19 <br /> Type Construction Disposal Site �-t �"�• �;` <br /> No.of Units Equipment Storage/Cleaning <br /> Location(s) <br /> 6. 0 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name x, ) Where Certified <br /> Plant Location ) 11 -.�. <br /> Plant Capacity No. Units Served <br /> 7. 0 LAUNDRY For July 1, -June 30, 19 _ + I <br /> SIZE: ❑ Less Than 1,000 5q. Ft-, El More Than 1,000 5q. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> �0`17ne owner or linen"eteaenE �I,riate•etn t4,e t efsln r.�: 1 I r <br /> I7�UE#7 T8�1fiCf c3.•.;6 JC '•In r lP � I rrtlf '1F iC�;1� "rOr �� t , .. i <br /> I shall <br /> Tir7:'ICE D�fr..1"�r�{3C V�•,•w t nn• 1 � <br /> f?77s 1. ,mr�H DI Lrs „i.:+. - } -71 !'1,. itis pit i5 is,ll 'f,[S�'Hll ncte,;.ployanyp$rSa€1 <br /> N , r "'� _„l��CCL(C l:'CI'liTsBi:S C:7.13NtEi�i Ff u;�. Lr i-...iL i.l -,3.:... ata,.ri• i�4 lip'ii .i-!?. � 1.r-3fe� .ri �' � _ <br /> I hereb ce hat I have prepared this'applioa n;a�nd'that the work will be done in-accordance with San Joaquin County <br /> ordinances, state is nd les a e do f t e Sa aquin Local Health District. <br /> i <br /> APPLICANT'S SIGNATU -_ { <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> I 0 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH; ❑ January 1_&Received By 31 El Jul,1 &Received By July 31 <br /> 1.r y J, ' . <br /> BILLING f REMITTANCE ��* .` REMIT''”j <br /> BASE EXPLANATION f , $ AMOUNT D E CHECKED-I <br /> DATE -REMITTED AMOUNT'ii <br /> FEE C l <br /> LESS <br /> r PRORATION <br /> PLUS - <br /> PENALTY <br /> OTHER <br /> OTHER _4 <br /> i Received by t Dae Receipt No: Permit.— - Issuance Date Mailed Debyered. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELTON AVE.,P.O.Box 2009 - STOCKTON.r'•'"- <br />