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APPLICATIONf. <br /> i (FLPon-Transferable, Revocable,and Suspendap <br /> Nle) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE y <br /> LIQUID WASTE <br /> Application is hereby m to car on business in the unsdlc onal area of the San Jo a uincc`ocal Health Distrlcy}L� _ <br /> ttusiness Name (DB Q) �d 6 ObF�IP SFsPLie& Address 4� <br /> ownerM I [ )AS4CA4 Address 17eS $d, DEL EA-7' <br /> :irm Partners, Addresses and T hgpe Num ars <br /> `3usiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date g�� <br /> 'lease check Applicable Category(1-7)and Fill in the Required Infor n idon <br /> -I. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June'30, 19 Disposal Sites <br /> )ascription(Make/Yr., CV.r) W <br /> ,serial No. CAL. License No. CAL. License Renewal No. 0 <br /> Capacity Gal.,Weights&Measures No. <br /> ?quipment Parking Address <br /> 1. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> Vo. of Chemical Toilets Stored �C <br /> —3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Daterrime p <br /> 7. 9 SANITATION PERMIT I V. <br /> Job Adtl ss/Location dd S Jw <br /> Owner/� FO 4 7ju._ .112T Address •Qr �� _ O 6,y <br /> SEPTIC TANK CESSPOOL LEACHING FIELD F SEEPAGE PIT ❑ PACKAGE PLANT <br /> If PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 Q <br /> Type Construction Disposal Site <br /> .,,No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 { <br /> Operator Name Where Certified �r <br /> Plant Location <br /> rPlant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For J4 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft- <br /> DRY <br /> LDRY CLEANING, Chemicalfltsed/Amount/Mo. <br /> r< ' <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,an54utqs and regu�llation/s/;of�the San aquin Local Health District. <br /> �A.PPLICANTS SIGNATURE X --J( CSC-IiL�-� <br /> FOR DEPARTMENT USE ONLY —� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 d Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATIONBILLING <br /> DATE RE TT O AMOUNT DUE CHECKED <br /> AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - - <br /> OTHER <br /> OTHER <br /> - iia Y /In /fin I �U� <br /> _ Received by Dat I' Rece,pt No. Permu No. Issuance Date Mailed Delivered <br /> _R APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 20M STOCKTON,CA 06an <br />