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Applications Will Be processed When Submitted Properly Completed.Be Surte'To Sign The Application. <br /> . r <br /> APPLICAVON <br /> ' (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE. <br /> Application i erebyma `to c ryan business in the Jurisdictional area of t <br /> Business Name(DBA) n aquin LacalONealt i rice <br /> z Owner " Address <br /> Firm Partners,Addresses and TelAddress <br /> ep umber <br /> a Business Telephone No. �- <br />' I Emergency Telephone No... <br /> :1 Contractor Licence No. <br /> L Applicants Name(Print) <br /> Please check Applicable Category 1� Title „•.pate <br /> 9 ►Y( �and Fi{1 In the Required informatkan <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) ' { <br /> For duly 1, - - June 30, 19 - Disposal Sites <br /> Description(Make/Yr.,Calor) <br /> Serial No. CAL. License No, <br /> CapacityCAL.License Renewal No. <br /> Gal.,Weights$Measures No. <br /> Equipment Parkin Address <br /> 2. 11.PUMPER YARD ` <br /> For July 1, June 30, 19 <br /> No,of Vehicles Stored <br /> No.Of >grnical Toilets Stored x <br /> 3' ❑ PERC1. OLATION TEST <br /> R,--S:or A.C.E.Name I '} .`x � ., . ....-._ . <br /> _ .. "� R.S.or R.C.E.No. <br /> Test Lobation Test Date/Time , <br /> 4•_, •'tANITATION PERMIT. G ( { <br /> Job Address/ cati <br /> Owner Address ' <br /> SEPTIC TANK ❑ CESSPOOL- LEACHING FIELD )9 SEEPAGE PIT ❑ PACKAGE•PLANT 1 <br /> PERMANENT ❑ TEMPORARY NEW�Y" E 13REPAIR :f ❑ OTHER { + s <br /> 5, ❑ CHEMICAL TOILETS For July,!,'June 3o, 19 <br /> Type Constructix <br /> on .rp q <br /> +. 'Ois osak'Site <br /> No.of Units- - 1 Equipment Storage/Cleaning Location(s) <br /> `• &. ❑ PACKAGE TAEATMENT PLrANT For July 1, June 30, 19 <br /> If <br /> Operator-Name .".K F <br /> Where Certifled # <br /> Plant Location ._ ' . f r <br /> Plant Capacity ,' <br /> ' ! No. Units Served - » <br /> 7. ❑LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑'Less fhan'1,0oo Sq.fit., ❑ More Than 1,000 Sq. Ft. I <br /> ❑ DRY CLEANING,Chemicals lysed/Amount/Mo. <br /> }1�hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,stale laws,and rules and r ulatio of the SM <br /> Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X �ii r <br /> _ <br /> i, <br /> �FORAEPARTMENT USE ONLY <br /> 'fe8.13 Due: ANNUALLY �]PER UNIT ❑ PER SITE ❑ EACH <br /> ❑ January t d F! i <br /> i S By January 31, ❑ July 1&Received By July 3i <br /> ty 1 `• ; EASE EXPLANATION BILLING REMITTANCE S REMIT <br /> re GATE` DATE /11!AEMITTEO AMOUNT DUE CHECKED <br /> FEE D - AMOUNT I <br /> Sa <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY .* <br /> r <br /> OTHER ��y� .{ ` -� t� ,• r <br /> OTHER _ - Y ` - ' 5 <br /> 'I <br /> Race vea ey Date I /.0 T l ! <br /> ' Receipt No. Permit Ne. uanc D ' Mailed <br /> APPLICANT—RETURN ALL COPIES TO: �i=NY1RONMEN7AL NIE,RiTN 1'ERMI7/&ERYICES Aefivered <br /> ' 1801 E.IiAZELTON pYE.,P.O.Boy 2p09 STOCKTON.CA 95201 <br /> l <br />