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APPLICATION <br /> II r Non-Transferable, Revocable, and Suspendattil"""li <br /> ENVIRONMENTAL HEALTH PERMIT —` SEPTAGE <br /> LIQUID WASTE <br /> Application.is hereby de to carry on bus!pe in the jurisdictional area of the Sa Joa ' Local Health/rLJ�i/ ttriJcjt f1 <br /> f�'i`.• . <br /> N Business a (DBA) ' - •± Address `s <br /> z Owner-,& AddressK144 AA <br /> ,.. <br /> J Firm Partners, Addresses and Telephone Nurtlbers y, > �E ��{5`-25/1 <br /> IL Business Telephone No. Emergency Telephone No. S <br /> Contractor Licence No. -Z <br /> L Applicants Name (Print) r9 G <br /> �� Title OA)4- Date .12 �ff <br /> Please check Applicable Category(1-7) and Fill in the Required Information I <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 'I <br /> No. of Vehicles.Stored it <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST ;I <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> s <br /> Test Location Test Date/Time <br /> 4. 2 SANITATION PERMIT I <br /> Job Addr ,s}s/Location <br /> Owner Address Qce)4)ff.. <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT D TEMPORIARY ❑ NEW D REPAIR ❑ OTHER <br /> r 5. ❑ CHEMICAL TOILETS Fo0july 1, -June 30, 19 �1 <br /> Type Construction Disposal Site <br /> ty� <br /> 1 No. of Units `P Equipment Storage/Cleaning Location(s) <br /> r 6. El PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> I Plant Location <br /> Plant Capacity No. Units Served <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 hereby certify that,I have prepared this applic n and that the work will be done in accordance with San Joaquin County <br /> ordinances, state las,`andZ;n� egulatio a an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> l FOR DEPARTMENT USE ONLY <br /> ii Fee Is Due: ❑ ANNUALLY PER UNIT _ ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31. ❑ July 1 &Received By Juty 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> I =BASE.;I EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> 4 <br /> { � AMOUNT <br /> O <br /> FEE Q <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY 'I ' <br /> .:.OTHER <br /> OTHER <br /> Received by Date iI Receipt No. Permit No. Issuance VaipMailed peiivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON C 95201 <br />