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APPLICATION <br /> I" Non Transferable, Revocable, and Suspendable' SEPTAGE <br /> cNVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of th San Joaquin Local Health I <br /> N Business Name (DBA) r�a,T�J S��T�-` � �� Address d U 6G 7 <br /> a Owner—_-. _ —_--- ____— Address AIJK 171989 <br /> u Firm Partners, Addresses and Telephone Numbers <br /> EL Business Telephone No. ��Z 7 Emergency Telephone No. <br /> ENVIRONMENTAL HEALTH <br /> Contractor Licence No. _ tKIVII I /SERVICES <br /> IApplicants Name (Print) _-_____ —__._._.__--_—__._ Title ---.-- ------ - Date--- <br /> Please check Applicable Category (1-7) and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,- I _ - June 30. 19 _- -_ Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address - <br /> 2. 1:1 PUMPER YARD _ -------------- ------------ <br /> For July 1,... _.... .. June 30, 19 <br /> No. of Vehicles Stored __— ---No. of Chemical Toilets Stored-_ ---- -- - -- -- <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name �/�Lr9 /P,cE C/ R.S. or R.C.E. No. <br /> Test Location In 5 " g7' 6 _ Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location -- <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <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 /> Operator Name ___ __ - —.___. __ _ __ Where Certified ------- _ .._ <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 INnr <br /> prepare this ap ion and at the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, es a la on o the Sa uin Loca Itp�piStr°.etT <br /> APPLICANT'S SIGNATURE -- -- v\ L- <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 11 EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> -- REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE [_> �1 \ �.1 C l� ��. �► ''•.... <br /> LESSV fill <br /> PRORATION v <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No. Issuance Dele Mailed Delivered <br /> '�- APPLICAN ET RN ALL COPT S TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 --9TOCKTON,CA 95201 - <br />