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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 /> LIQUID WASTE <br /> Applicati he. b mpde to Cajj..[[YY o�n business in the jurisdictional area of the S Joaquin LL,ocal Health Dig rict <br /> F Business Na�+(OBA) ARI Ies 1Sf1CIC HOe SNL Address es O &T c-ol j /i� <br /> i Owner /IM CAA6r/e Address <br /> 7 Firm Partners, Addresses and Telephone Numbers 82 b- 650-Y <br /> iBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. 1Y39/ <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category(1-7)and Fill In the Required Information 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(MakeNr.,Color) <br /> Serial No. CAL. License No. CAL. Licc.se 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 <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 Location Test Date/Time <br /> 4. ❑ SANITATION PERM[ <br /> Job Address/Location gievd mo-s504/C Rc <br /> Owner w/H/J1e2 Address <br /> ED SEPTIC TANK ❑ CESSPOOL IS LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site /900 GIA/ S'epxc 7a l^& �r— 901 /04tH <br /> No. of Units Equipment Storage/Cleaning Location(s) I�NYS / /.5 vX /L' I Ay/tct 3Ge <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location n <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, les and <br /> pregulations of the nJelin Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X " <br /> 1^,nn - Z-� <br /> u\,,O r7 <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Doe: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE ,DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> OU <br /> EEE <br /> lAfr <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Racawe0 by I Oat Receipt No. Permit No, Issue Dete Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES K01 E.HAZELT E.,P.O.ae.2009 STOCKTON,CA"201 <br />