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Applications Will Be Processed When Submitted Properly Cor4leted. Be Sure To Sign The Application. <br /> APPLICATION I — <br /> ` (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQU10 WASTE <br /> Application is rebY Tade3p carry on business in th risq4ytional area e4an Joaquin Local Health Distri ; <br /> Y ,F Business Name(DBA � +- Ad less 0 �' 7b <br /> aOwner ddress <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. � Emergency Telephone No. <br /> Contractor Licence No. ;IM <br /> L Applicants Name (Print) Title Date �6� 7 <br /> Please check Applicable Category (1-7)and Fill in the Requirdh Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color). !� <br /> Serial No "�- CAL. License No. !� CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address ! <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles.Stored i <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name - »w+-R:Sc or R'.C.E:-No. t <br /> Test�Lo on G Test Date/Time <br /> M !M <br /> 4. SANITATION PERMIT <br /> el <br /> Job Address/Location, Gt1 Z <br /> Owner °� d i Address <br /> SEPTIC TA K ❑ CESSPOOL "ACHING FIELD L ITS ❑ PACKAGE PLANT }~ <br /> ®PERMANENT ❑ TEMPORARY NEW ❑ REPAIR !� ❑ OTHER ` I <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> r No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name ii Where Certified <br /> Plant Location I \ <br /> Plant Capacity , No. Units.Se_rved <br /> r 7. ❑ LAUNDRY .For July 1, -June 30, 19 E� - <br /> ' SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. I <br /> 11 DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordant w an Joaquin County <br /> ordinances, state laws, and rules and r ulations of the San Jo a uin Local Hlfealth District. ,y <br /> i" APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Ja ua 1 ❑ July I &Received my 31 <br /> BILLING REMITTANCE REMIT <br /> RASE EXPLANATION ` $ /D� AMOUNT DUE CHEgkED <br /> DATE DATE !I R I TE AMOUNT irl <br /> FEE <br /> LESS <br /> PRORATION ' <br /> PLUS 1` <br /> PENALTY <br /> OTHER I� . <br /> i <br /> OTHER s11 <br /> a <br /> Received by - - Date L Receipt No. Permit N" 11suande DM6 Mailed. - Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />