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inl,NRuanuns W111 ll 1'1,)Cpgkvu WImn 9""ll" f'rrlpf3riy Gaufll"`l@il @tlrp To §Ilp Th@ Appilcallo— � <br /> _— <br /> APPLICATION �� <br /> (Fpr Non-Transferable, Revocable, and Suspendable) ti, <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hore y made to carry on business in the jurisdictional area of the an oaquin Local Health District <br /> o Business Name (DBA) iQJS " r'' �S ,�G , Addressl'.p ' <br /> Owner_ y, Addluss <br /> Firm Partners, Addresses and Telephone Numbers <br /> 3 Business Telephone No. Emergency Telephone No. 0Contractor Licence No. <br /> Applicants Name (Print) �L2L !S — TitleST__� pate <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 _ Disposal Sites <br /> Ila Description(Make/Yr., Color) _ <br /> Serial No. _ CAL. License No.---- _ .__ CAL. License Renewal No, <br /> i{ Capacity Gal„Weights a Measures No, <br /> } Equipment Parking Address <br /> t 2. ❑ PUMPER YARD —��-- --For July 1, June 30, 19 x. _ <br /> No. of Vehicles Stored ' <br /> No. of Chemical Toilets Stored _ 411,3. 11PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.,or R.C.E. No. <br /> Test Lo on Test Date/Time _ <br /> 4. 2 SANITATION PERMIT <br /> Job Address/Location_jr <br /> } l� �sry/4 <br /> Owner7� y—/C Addres,.s�.,�_ _���f _ _ _____ <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 13 SEEPAGE PIT ❑ 3? `(' 7CfiE PLANTT~ <br /> e'PERMANENT ❑ TEMPORARY © NEWQRE []{'r T <br /> REPAIR ; OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type - Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locationfs? <br /> 6. ❑ PACKAGE TREATMENT PLANT For Juiy 1, - June 30, 19 <br /> ji Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> Ij SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. _ ! <br /> i <br /> i <br /> f1 <br /> I hereby certify that I have prepared this application and that the work will he done its accordance wilh San Joaquin County <br /> ordinances, state laws ules and gula ' of th an oaquln Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNI_iAl_I_Y ❑ hrtl UNn ❑ rl-I:r;i I I ❑ 1 Ar'.Ii ❑ .Innn.uv I x li„ ,,v, .l lay.i:,,,,,.i,y al ❑ ,n ly I &IcP:ewr it uy,1wy JI <br /> 1 <br /> E31LE_ING REMITTANCE 5 REMIT - <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY i <br /> OTHER <br /> OTHER <br /> Received by Dale Receipt No, Permil Na " '� ''"i-;Ifarire U.•ate-�' --Mailed'-"— De wer <br /> -- APPLICANT—All ALL COPIES TO: FNV,RONMENTAL 11Enr.Tn PE13MII'rSCRVICE8 1601 f-RAZ.ELTON AVE.•P"O.Unx 2009 STOCKTON,CA 05201 <br />