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APPLICATION <br /> or Non-Transferable,Revocable,and Suspends. <br /> r/ (� ti.r ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> v LIQUID WASTE <br /> Application ere made ry o��nnn lllr,,, siness iNthg urisdictional area of thetS�a Jo7a in•LTocal Health Dis Ict <br /> „Business Name (DBA) V7 r�/1'Af l I <br /> Add---- <br /> z Owner Address $R-/►'�C ____ _ <br /> Firm Partners, Addresses and T ryror�hone/Numbers <br /> iBusiness Telephone No. �Ql s`4'3�� Emergency Telephone No. <br /> Contractor Licence No.—e7 3 <br /> Applicants Name (Printfff <br /> C i�/V/✓�S _Title CkWeR Date <br /> Please check Applicable Category (1-7)and Fill in the Required 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. l <br /> Capacity Gal., Weights&Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD C <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST - <br /> R.S.or R.C.E. Name R.S.or R.C.E.No. <br /> Test}ocation Test Date/Time T` <br /> 4. 1 SANITATION PER 1 .�– - <br /> Job Address/Lo Ation %�gOD i D N Z N /p N C <br /> O ner sat"4' Address <br /> SEPTIC TANK ❑ CESSPOOL rrrT��LEACHING FIELD. ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY IriNEW ❑ REPAIR ❑ OTHER <br /> S. ❑r CHEMICAL TOILETS For July 1,- Une 30, 19 <br /> Type Construction Disposal Site hV' <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 <br /> 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 application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws.apd/ulp5 and regulations f the San Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑.EACH ❑ January I&Received By January 31 ❑July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNNT <br /> FEE 7/ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> \bM <br /> Z 7 <br /> Received by Date Receipt No. Permit M. Issuance Deto Mailed Deli re0 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1001 E.HAZELTON AVE.,P.O.Bot 21109 STO KTON,CA" <br />