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APPLICATION <br /> ,..f. '"•; (For Non-Transferable, Revocable,and Suspendable) SEPTAGI <br /> ENVIRONMENTAL HEALTH PERMIT `~ <br /> LIQUID WASTE <br /> Application is qiy-made to c on�sme In the jurisdictional area of the SSa/annJ�Jo�aaq``uinL cal He th District <br /> ,�Business Name (DBA) _—. Address - mol' <br /> ~ J' G` 7-210 Address— <br /> zQ Owner / — <br /> u Firm Partners, Addresses and Telephone Nu bens r_ <br /> Business Telephone No. — � � '� Emergency Telephone No. <br /> Contractor Licence No. i <br /> Applicants Name (Print) _ _. Title Date -— <br /> Please check Applicable Category (11-7) and Fill In the Required Information <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. License Renewal No. <br /> Capacity _ _ Gal.,Weights 6 Measures No. — - <br /> i <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 'ocation _ Test Date/Time <br /> 4..'. SANITATION PERMIT <br /> Job Address/Location <br /> Owner - �- - Address. <br /> ❑ SEPTIC TANK 13 CESSPOOL ❑ LEACHING FIELD $EEPAGE PIT 11 PACKAGE PLANT <br /> [] PERMANENT ❑ TEMPORARY ❑ NEW OREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILET$ For July 1,-June 30, 19 <br /> Type Construction _ Disposal Site <br /> No. of Units _ Equipment Storage/Cleaning Location(s) <br /> 6. I:1 PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> Operator Name t --- Where Certified _ - <br /> Plant Location L <br /> r r Plant Capacity No. Units Served _ <br /> ___ � -- <br /> 7. ❑ LAUNDRY For July 1l`: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 /> fKart»arreerarrNcanas� t <br /> vw"www"%1 big,11 go <br /> toot M*epvrfvr*w*Wftvjjtk Wwtilch Mispermit is issued,I shwl not employ any person <br /> in each rRmnst as tafxoertla U- to ttrRftlnan'S comp mIsdo Haff!of Ca,MmIa.' f � <br /> ConveseWs w aeb-camtiodwo s p o t m cw$%* ft "Rol�: '1 cemIjil that inlhe Aerl Once 61 tflework for which this permit is issued.I shall <br /> anploy pmom 6U*0 to wakmarlfatc0otpc+asatfon tr■aN aflterrlta." 1 <br /> I hereby certify that I have prepared this appli tion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rule regulatio of the Sa oaquin Local Health Distri't. <br /> APPLICANT'S SIGNATURE X - - <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE El EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Recmvim!By July 31 <br /> _-�- "" HEMI f <br /> BASE EXPLANAI ION 't -DATBILLING REMITTANCE S AMOUNT DUF CHECK Fn <br /> _GATE DATE REMITTED AMOUNT <br /> FEE --- - <br /> LESS <br /> PRORATION <br /> PLUS - C'o.�/Q� 4,r <br /> PENALTY <br /> OTHER �r <br /> OTHER ..� �� �. �.v-- - - . ._ .r.-�. —• — <br /> 12ecbrved by Date Receipt NO. Permit NO. Issuance Dote Mailed Delivefed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E-HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />