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APPLICATION <br /> rr Non-Transferable; Revocable,and Suspendabl <br /> Y'ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is ere made to car on bus' ess in the jurisdictional area of th/e�an Jo quip Local Health District <br /> ca <br /> Business Name(DBA)_ ,,� � �f �r� t NMs Address <br /> i Owner <br /> a Address <br /> j.Firm Partners, Addresses aril Tele hone Numbers <br /> IL <br /> Business Telephone No. " Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> L Applicants Name (Print) '7 TitDate r "� <br /> Please check Applicable Category (1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) py <br /> For July 1, June 30, 19 Disposal Sites co <br /> r" <br /> Description(Make/Yr., Color) 1 0 M — -� <br /> Serial No, CAL. License No. CAL. Liccrise 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. f SSANITATION PERMIT <br /> Job Address/Location 7,0�9� i41 <br /> Owner. 1CM Address liL+t` eJIT"S. <br /> ❑ SEPTIC TANK ❑ CESSPOOL 2'CEACHING FIELD B SEEPAGE PIT ❑ PACKAGE PLANT <br /> B-PERMANENT ❑ TEMPORARY ❑ NEW 21REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units. Equipment Storage/Gleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June'301 19 <br /> Operator Name WhereCertified <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 1'h ve prepared this application a that the work-will be done in-accdrdance with San Joaquin County <br /> ordinances, stateA!Zs&d rules a regulati oft San J aquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: El ANNUALLY ❑ PER UNIT,_ ❑ PER SITE ❑ EACH ❑ January 1&• c v BJanuary 31 ❑ July 1 &Received By July 31 <br /> BILLING RE TTANCE REMIT ' <br /> BASE EXPLANATION DATE AMOUNT DUE CHECKED <br /> ATE EMITTED AMOUNT <br /> FEE . � � So <br /> LESS <br /> r <br /> PRORATION <br /> PLUS <br /> PENALTY / <br /> OTHER <br /> OTHER <br /> a � <br /> Ce `� 8a JE <br /> Rel4etl by Date Receipt No, permit No. Issua a Da a iled Delivered I" <br /> • <br /> APPLICANT- RETURMALL COPIES TO:' ENVIRONMENTAL HEALTH P.ERMIT1SEAVICES `;1601 E.-HAZELTON AVE.;P.O.Sox 2009 ': STOCKTON,Cly 95201 <br />