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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> _ (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is ereby made to carry on business in tfle juri dictional area of the San Jos uin Locai Health D}�" trict <br /> ..asiness Name ( A) 'arc Address �� � �6 7 <br /> cOwner Address — <br /> Firm Partners,Addresses and Telephone NumbQrs <br /> CL <br /> Business Telephone No. S! Emergency Telephone No. <br /> Contractor Licence No. Z 2- f9 <br /> L Applicants Name(Print. - U S4- �e Title Date - 4 ' 5(0 <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, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color)— ;Z7 1 <br /> Serial No. ` CAL. License No. _CAL. Liccnse Renewal No. <br /> Capacity -Gal.,-Weights&Measures fVo <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD 1 <br /> For July I, 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 Kation Test Date/Time rJ <br /> 4. LJ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address C <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD" I_B,rSEEPAGE PIT El PACKAGE PLANT;� <br /> ❑ PERMANENT 13 TEMPORARY DINEW L�- EPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 17 unJune 30,19 � <br /> ' 1; � 3•! <br /> to Construction � 1 Disposal Site <br /> of Units i " I Equipment Storage/Cleaning Location(s) <br /> b. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name V 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., El More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> r <br /> I hereby certify that I have prepared this application and that the work will be done in accordant th San Joaquin County <br /> ordinances, state laws,and rules!p5v regulations of the J uin Local Health District. <br /> APPLICANT'S SIGNATURE X /��'.L�Z��� e <br /> 47 <br /> FOR DEPARTMENT USE ONLY- - <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Januarya ived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING RE TTANC $ AMOUNT DUE CHECKED <br /> DATE ATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS 1 <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 649 <br /> Received oy Date Receipt No. Permit No. Issuance Date Mailed Delivered— <br /> APPLICANT—RETURN <br /> eliveredAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952111 <br />