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APPLICATION �. <br /> it Non-Transferable,Revocable, and Suspendab' <br /> ENVIRONMENTAL HEALTH PERMIT `'� SEPTAGE <br /> LIQUID WASTE <br /> Application is ere ode to car on bus' ess in the jurisdictional area of the„S�Joaquin Local Health District l <br /> CAF business Name (DBA) Address //JJ � <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and-telephone rs <br /> aBusiness Telephone No. "9 7 Emergency Telephone qju <br /> Contractor Licence No. Acitol;11,11;111 <br /> r <br /> Applicants Name (Print) w Titl 5TH 'e Date r <br /> Please check Applicable Category (1-7)and Fill in the Required Information S <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. 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. E SANITATION PERMIT <br /> Job Address/Location 7,0> 99 W <br /> Owner �G������ td!dre!s!s <br /> ❑ SEPTIC TANK ❑ CESSPOOL 2-[EACHING FIELD I1SEEPAGE PIT ❑ PACKAGE PLANT d <br /> &'PERMANENT ❑ TEMPORARY ❑ NEW CIREPAIR ❑ OTHER oIU <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <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 /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity Na. 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 h ve prepared this application a that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws d rules a regulati of t an J aquin Local Health District. <br /> APPLICANT'S SIGNATURE ol <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i & c ve 6 January 31 ❑ July 1 S Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING RE TTANCE AMOUNT OUE CHECKED <br /> BATEATE EMITTED AMOUNT <br /> FEE '[ <br /> LESS <br /> PRORATION <br /> PLUS / <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. i Issua a Dae Wl= <br /> Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2004 STOCKTON,CA 95201 <br />