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r <br /> APPLICATION <br /> Non-Transferable,`Revocable, and Suspendabin <br /> -ENVIRONMENTAL HEALTH PERMIT - SEPTAGE <br /> LIQUID WASTE <br /> Application IS ere made to carry on busjpess in the jurisdictional area of th/eaJ�aan�n Joffq�uin Local Health District Q <br /> w Business Name (DBA) _ � �•- � Address�..� �ZGi <br /> �— <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. �� Emergency Telephone,No. <br /> Contractor Licence No. <br /> Applicants Name(Prink) T ^G �`3 Titl �� Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information S <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Q <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licznse Renswal 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. BISANITATION PERMIT <br /> Job Address/Location089� <br /> Owner ',!C 6e Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL 2-tEACHiNG FIELD 2 SEEPAGE PIT ❑ PACKAGE PLANT d <br /> R-PERMANENT ❑ TEMPORARY ❑ NEW 131REPAIR © OTHER CZ <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 rim <br /> Operator Name Where Certified 1 <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 that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws d rules a regufow lati , oft San J aquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & 4. B January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING RE TTANCE AMOUNT DUE CHECKED <br /> DATE ATE EMITTED AMOUNT <br /> FEE may'S <br /> LESS - <br /> PRORATION <br /> PLUS 11f <br /> PENALTY <br /> OTHER <br /> OTHER _ <br /> Received by Date - Receipt No. Permit No. I Issuarice Dae Ntfled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITJSERYICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 45201 <br /> i <br />