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ii .-.pp....a.,... n... ..... . .........aw .....:..vr............ . ,..T..:..� ...w..p....�... .... .....� .� ...a.. ......-r r..��..�... <br /> ?' APPLICATION <br /> (—Non-Transferable, Revocable, and Suspendablel <br /> w ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application.is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> en Business Name (DBA) a Address <br /> a Owner. / r . r 'lei_ Address O a d <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. w+✓ "� / d D GeiL <br /> LApplicants Name(Print). Titley �`"� Date <br /> Please!check Applicable Category. 1-7}and Fill In.the Required Information <br /> I. ❑ YPUMPER VEHICLE PERMIT,REGISTRATION (FOR EACH VEHICLE) <br /> I For July 1, June 30, 19 <br /> Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity ii Gal.,Weights &Measures No. <br /> Equipment Parking Address , <br /> 1 2. ❑EPUMPER YARD <br /> For July 1,. June 30, 19 '+ I <br /> No. of Vehicles Stored '. 4 <br /> No. ofChemical Toilets Stored I� <br /> i <br /> 3. ❑ PERCOLAtiON'TEST <br /> R.S.or,R.C.E. Name R.S. or R.C.E. Na. <br /> t Location II Test Date/Time ` <br /> - 4. SANITATION PERMIT <br /> ob Address/Location <br /> Owner:;' ^r a Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL-, ❑ LEACHING FIELD SEEPAGE PIT U PACKAGE PLANT ` <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEWREPAIR ❑ OTHER- <br /> 5. <br /> THER-S. O'CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No.oflUnits II Equipment Storage/Cleaning Locations <br /> S. ❑''PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location ' <br /> Plant Capacity I 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 /> •II I; <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Iordinances, state laws, ak d rules aulati of the San Joa oval Health District. <br /> APPLICANT'S SIGNATURE X 9 <br /> a <br /> i� FOR DEPARTMENT USE ONLY 1 <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July t &Received By July 31 <br /> BASE ? EXPLANATION BILLING ITTANCE $ REMITAMOUNT DUE CHECKED <br /> i DATE BATE REM TTED AMOUNT <br /> F'EE �R .i <br /> LESS l / <br /> PRORATION <br /> PLUS !i <br /> PENALTY y <br /> OTHERAl <br /> DTHER <br /> R eived by Date Receipt Dro. Per it Nof Issuance Dat Mai Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON .Box 2009 STOCKTON,CA 95261 <br /> l <br />