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."JJIILCILIUIlb VVIII oe'r1uLrabeU VVIW(i ouurnmeu rrp ert Lom ieteu. oe Aure to zo n Ine Appitcaxion.��, <br /> APPLICATION <br /> '3 (For Non-Transferable, Revocable,'and Suspendable) <br /> ENVIRlDk_ �i <br /> NL k &LTH PERMIT. SEPTAGE I <br /> LIQUID WASTE <br /> Application i ereby m de to carry on business Ii1•the:jurisdictional area of the•SanJoaquin Local-Health District I� <br /> rBusiness Name (DBA) —Address?,�Qd <br /> zOwner Address �— <br /> .Firm Partners, Addresses and Telephone-Numbers :i <br /> cBusiness Telephone No. — 9�[? - Emergency Telephone No. <br /> Contractor Licence No. E <br /> L Applicants Name (Print, Title 'r-C37 J91r�' Date � F <br /> Please check Applicable Category (1-7) and Fill in the Required Information . <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)-J-:" <br /> For July 1, June 30, 19 -'Disposal Sites <br /> Description(Make/Yr., Color) - 0 _ <br /> Serial No CAL. License No. CAL. License Renewat,No. I i <br /> Capacity'~'° Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 i <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST. E <br /> R.S. or R.C.E. Name A.S. or R.C.E. No. ;I <br /> Test LocationTest Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location <br /> E <br /> 0 �r c d o Addre� i <br /> n SEPTIC TANK CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT !f <br /> ❑ PERMANENT TEMPORARY ❑ NEW - ❑ REPAIR ❑ OTHER- <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19' `^ !� <br /> Type Construction DisposaFSite " <br /> f <br /> No. of Units Equipment Storage/Cleaning Location(s) M I <br /> 6. ❑ PACKAGE TREATMENT PLANT 'For July l.--June 30, 19 I <br /> Operator Name Where Certified 1 <br /> Plant Location I <br /> Plant Capacity __ -_— Na Units Served y <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 ` <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq- Ft. ' - <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I herebycertify.that I have re red this application and that the work will be done in accordance with San Joa, uin Co fY P Pp 9 Y <br /> ordinances, state laws,and rul an lations f the San Joaquin Local Health District. pw <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY f <br /> Fee IS Due. ❑ ANNUALLY'•�f•`'❑ PER-UNIT- �_�.❑ PER SITE --•-❑ EACH '0 January 1 &Received By January'31 "❑ July 1-&'Received By July 31 i <br /> REMIT h„ <br /> BILLING •REMITTANCE <br /> --.BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE ATE REMITTED r- .AMOUNTh <br /> FEEJ. <br /> LESS- <br /> PRORATION <br /> ESSPRORATION <br /> PLUS <br /> PENALTY _ ,� - - �• - a _- <br /> OTHER I <br /> .OTHER <br /> 7AL 9/12 <br /> Received by Date - Receipt No. _ Permit No. - - Issuance DaI6 Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - - - 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />