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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUIB WASTE u <br /> Applic is hereby"e to carryon bus' sent a urisdi tional area of the an Joa uin cal Health District <br /> m Business Name (DBA) �/-� "` ���� MSz� Address ./ <br /> .����' ' <br /> 4 Owner__A 0�itC& Address <br /> J Firm Partners, Addresses and Tele hon, Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. 1 <br /> Applicants Name (Print) Title - w Date/,�2 <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) t <br /> For July 1, June 30, 19 Disposal Sites 1 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccnse Renewal No. <br /> Capacity, Gal., Weights & Measures No. <br /> Equipment Parking Address ) <br /> 2. ❑ PUMPER YARD 1 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored 4 <br /> No. of Chemical Toilets Stored 0 <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. Ur SANITATION PEIT l <br /> Job Addres Location-M& �1 114 oo 4ee SToll e-le a J� ♦— t <br /> Owner 1Zkt?C—N S Address � '6�tAW <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT C/} <br /> PERMANENT ❑ TEMPORARY ❑ NEW XREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 T E <br /> Type Construction Disposal Site <br /> � �i <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 90PACKAGE-*TREA;TME`NTYPLA`NT For July 1, -June 30, 19 ` <br /> Operator NameV�r Where Certified <br /> Plant LocatYonxp� * <br /> Plant Capacity, No. Units Served '1 <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 /> d <br /> F <br /> I hereby certify that I have prepared this application and that the work will be done in accordance-with San Joaquin.County ) <br /> ordih antes, state la s, and yles and regul tions of t e San Joaquin L cal HeaIth#'Pistrict. <br /> P S I44 <br /> APPLICANT'S SIGNATURE X ae <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> d <br /> Fee Is Due: ❑ ANNUALLY .:❑ PER UNIT ❑ PER SITE ❑ EACH El January 1 &Received By January 31'. ❑ July 1 &Received By July 31 <br /> #.�'�'�""--.•. :�----.._-_..--- ._.._._..._._....- — --------- ---- d REMIT <br /> BILLING REMITTANCE $ <br />_ BASE EXPLANATION AMOUNT RUE CHECKED <br /> DATE AMOUNT Lfj <br /> FEE <br /> LESS ` <br /> PRORATION A ! f <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r? <br /> -777 9 <br /> A o I cv9 171 <br /> —Received by ---s- Date -Receipt No.- Permit No. ! • Issuance Date' Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Bo=2009. STOCKTON,CA 95201 <br />