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Applications Will Be Processed When Submitted Properly Completed. BeSure io sign ine..NNhh.,aI�..••. <br /> APPLICATION <br /> A aSEPTAGE <br /> 1 (For Non-Transterable,Revocable;'and Suspendable) <br /> r ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> ;Application is he eby made to carry n business in the jurisdictional area of the San.Joaquin�Loaa�hHealth District <br /> Address,. <br /> mBusiness Name (DBA) <br /> z Address <br /> Owner <br /> aF. <br /> a Firm Partners,lAddresses and Telephone Numbers Emergency Telephone No. <br /> CL Business Telephone No. �+ ��7 <br /> a Z _ 3' <br /> Contractor Licence No. Title Date�� �-?��� 4 <br /> Applicants Name (Print) <br /> 1 � <br /> Please check Applicable Category (1-7)and Fill In the Required Information <br /> 1. ElPUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> I - June 30,19 Disposal Sites - <br /> For July 1, r. �r t e .1 '�i <br /> Description(Make/Yr., Color) �4 `- -•>- <br /> CAL. License No. CAL. License Renewal No: I <br /> Serial No. <br /> t <br /> Capacity <br /> i Gal., Weights& Measures No: <br /> Equipment Parking Address i <br /> 2. 13 PUMPER YARD ( ` <br /> For July 1, 'i June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored. <br /> L <br /> 3. ❑ PERCOLATION TEST 4` s <br /> R.S. or R.C.E. No. _ <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test�Locatio'n <br /> t <br /> 4. SANITATION PERMIT It e p �� '• <br /> Job Address/Location ZO <br /> Owner '` Address usvt <br /> ❑ PACKAGE PLANT <br /> ❑ SEPTIC`TANK ❑ CESSPO LLEACHING FIELD 11c��6E�P PIT 13 OTHER <br /> PERMANENT ❑ TEMPORARY EW REPAIR z}} <br /> . .,o.-'.F '1 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 . <br /> Disposal Site, <br /> Type Construction a r <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT ,.For July 1, -June 30, 19? i <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> N&'Units Served <br /> - Plant Capacity F r <br /> 7. ❑ LAUNDRY For July i; =June'30,19 - <br /> ` ) ❑ M1Aore Than 1,000 S �Et w• • • r �`� <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., �wh ( y^rr4 <br /> 4 <br /> ❑ DRY CLEANING, Chemicals Used/ATY6Wn <br /> 't/Mo. <br /> f <br /> HomcoEnitic�"�r€icallsear-n"s-e�: :xe'Ir <br /> r„rrtgp^tl'e- 1�� �p:'•Ir,"}Ir';t'c ;1�t< 14� '^',7? 1�Bi?�ihCi�':Irl:Q£.d,11,!Cllti'iSNC'.n1it15?SSU6d,lshaElnDierT;p10'fanyp£r'� 3 <br /> in such premie;as.o h o ie Ci g l Ii1'' <br /> Contract r'$ hiring tar sv'..�n1r� t21:gs1:rr ratf uro or"f9es the 'o19owing: "i certify is..”;n€i:a sr€ormance of;he Ltior^Inr which€his pertnitis issr� li,I sIT�I <br /> employ prsbls.stl�je�ct <br /> prepared this a that the work will be done in accordance with San Joaquin County <br /> f 1 hereby certify that I ha prrep application and ° <br /> and re ions f' an J n Lo4l Health District. �_ •`E.�w�4 ; #. <br /> ordinances, state laws, 9 .Qi i <br /> h'I _ <br /> APPLICANT'S S1%!ATURE X <br /> t j '+ ; FOR DEPARTMENT-USE ON - <br /> Feels Due: ❑ ANNUALLY 0 PER UNIT ❑ PER SITE 13 EACH 11 Jan r Received By January 31 ❑ July i &Receiv REMIT-'d By y 3i <br /> BILLING •- R N $ AMOUNT DUE CHECK 01 <br /> (ABASE EXPLANATION REMITTED AMOUNT <br /> - { RATE s <br /> FEE 4 . <br /> I LESS <br /> PRORATION �� { <br /> PLUS t <br /> PENALTY '} r <br /> OTHER <br /> OT <br /> Jssuan s 'ate Mailed Delivered <br /> Date :Receipt NO. Permit Na. r - <br /> Redeived by '`1641?E°HAZELTON AVE.,P.O.aox 2609 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES To- ENVIRONMENTAL HEALTH PERMIT/SERVICES . <br />