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APPLICATION <br /> Non-Transferable, Revocable, and Suspendabl <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is ere made to carry on bup ess in the jurisdictional area of th//e��aan�n Jop�q�u,in Local Health District <br /> mBusiness Name (DBA ��-Address �y`SQ <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> It a Business Telephone No. Emergency Telephone No. <br /> a Contractor Licence No. <br /> L Applicants Name (Print) 7_ Tit! STS Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information S <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) b Vv <br /> For July 1, June 30, 19. Disposal Sites _ <br /> Description(Make/Yr., Calor) <br /> CAL License No. CRL. Lfccase Renewal No. <br /> Serial 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 ir <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. f SANITATION PERMIT <br /> Job Address/Location ©g94y W4 lZ el��i1 —'°Efts <br /> Owner Y'�!G V Address - 44w, %--.wf <br /> ❑ SEPTIC TANK ❑ CESSPOOL 2 [EACHING FIELD IISEEPAGE PIT ❑ PACKAGE PLANT d <br /> &'PERMANENT ❑ TEMPORARY ❑ NEW BIREPAIR ❑ OTHER o� <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 r1� <br /> Operator Name Where Certified l <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 h ve prepared this application a 3 that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws d rules ago regulati&oft San J aquin Local Health District. <br /> APPLICANT'S SIGNATURE WX <br /> nw y <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due:-❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &M4-54 ve B January 31 ❑ July i &Received By'July 31 <br /> REMIT <br /> BILLING RE TTANCE <br /> BASE EXPLANATION DATE OATE EMITTED .AMOUNT DUE CHECKED <br /> AMOUNT <br /> O <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> C( <br /> Received by Date Receipt No, Permit No. Issuance Daefiled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />