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APPLICATION <br /> Non-Transferable, Revocable, and Suspendabl <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby/made to carry on business in the jurisdictional area of thq San Joaquin Local Health District <br /> Business Name (DBA)_. tJ1T-+cl-S TS`- — S..r�^—'3--e'c-" Address d 11,30)( 6673 IIV4,2 c�7 7 e'4' C-� _ <br /> aOwner—__..-------- _ .. _ __.-. -- - .-_----. Address— <br /> Firm Partners, Addresses and Telephone Numbers --- <br /> Business Telephone No. 5- Z:_,2�7 1 __ ._ Emergency Telephone No. <br /> Contractor Licence No. --- <br /> jApplicants Name (Print) ---__-.---• -._ Title .- -- —._---_ _.---_--_-- Date ...... ------_--_ <br /> Please check Applicable Category (1-7) and FIII 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 & 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 -_ --� f CR.S. or R.C.E. No. �7& <br /> Test Location . .`J._'_ . 7'_.-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 I tRve prepared this ap ion and at the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, n r es a is on o the Sa uin Loca It�iStr4etr <br /> APPLICANT'S SIGNATURE X ------- --- ------ ------ -- <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1&Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 3�^' (•> tt..�� <br /> 01 <br /> LESS "U 'J rl rill <br /> PRORATION <br /> PLUS <br /> PENALTY ---_-- --.-._-- __.._...----•--.. _. <br /> OTHER <br /> OTHER <br /> Received by —Dale Receipt No. Permit No. Issuance Date Mailed �Delivorecf <br /> APPLICAN ET RN ALL COPI S TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 9TOCKTON,CA 95201 - <br />