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F' Applications Will Be Processed When Submitted Property Completed, Be 5ure'TO sign 1 ne rapplF:nuen- <br />APPLICATION <br />Suspendable) <br />LESS <br />(For Non-Transterable, Revocable, and <br />SEPTAGE <br />ENVIRONMENTAL HEALTH PERMIT <br />PLUS <br />k; LIQUID WASTE <br />'?Lo <br />PENALTY <br />4 Applicat. 's hereb m e t r buss ss in the jurisdictional area of the San Joaq <br />y <br />I Hea�Dstn�c�y� <br />h lYll <br />AddressId <br />jjj Business ame (DBA) u' — _ y,f <br />' Address <br />a <br />Owner ' . -��- _ <br />C� a <br />J Firm Partners, Addresses and Telephone Numbers <br />No. <br />l , <br />Emergency Telephone <br />Business Telephone No. <br />_ <br />Contractor Licence No. _ *' <br />Title <br />Date 87 <br />Applicants Name (Print) �— <br />Please check Applicable Category (1-7) and Fill in the Required Information <br />REGISTRATION (FOR EACH VEHICLE) <br />�N <br />1. ❑ PUMPER VEHICLE PERMIT t <br />For July 1, June 30, 19 Disposal Sites <br />Description (Make/Yr., Color) I -.. CAL. Lic- Ise Renewal No. <br />CAI No. <br />-?License <br />Serial No. <br />Gal_. Weights & Measures No. <br />Capacity <br />Equipment Parking Address _ <br />2. ❑ PUMPER YARD <br />i For July 1, June 30, 19 <br />No. of Vehicles Stored _ <br />No. of Chemical Toilets Stored t <br />a <br />3. ❑ PERCOLATION TEST I R.S. or R.C.E. No. <br />R.S. or R.C.E. Name <br />Test Date/Time <br />,= <br />t Test Location <br />1 k <br />4. 11 SANITATION PERMIT <br />Job Addr ss/Location 40.j-2 <br />adv <br />r- Owner Y Address <br />SEPTIC TANK ❑ CESSPOOL LEACHING F1E1_D ❑}SEEPAGE PIT ❑ PACKAGE P <br />NT <br />❑ PERMANENT 1-1TEMPORARY NEW ❑ RE PIR 13 OTHER <br />5. 13CHEMICAL TOILETS For July 1, -June 30, 19 i <br />type Construction Disposal Site <br />Equipment Storage/Cleaning LOcat%n(s) <br />- <br />No. of Units <br />k <br />6. ❑ PACKAGE TREATMENT PLANT. For July 1, - June 30, 19 Where Certified <br />-.. <br />Operator Name <br />I <br />Plant Location <br />' No. Units Served <br />Plant Capacity ,I <br />j 7. ❑ LAUNDRYFor July 1, - June 30, 19:y <br />❑ Than 1,000 Sq. Ft. <br />SIZE: ❑ Less Than 1,000 Sq. Ft., More <br />T <br />❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br />j <br />t <br />I hereby certify that I have prepared this application and that <br />ordinances, state laws, an> rules and regulati of <br />APPLICANT'S SIGNA <br />Fee Is Due: ❑ ANNUALLY <br />FOR DEP <br />❑ PER UNIT L1. PER SITE ❑ <br />BILLING <br />BASE - EXPLANATION DATE <br />FEE <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />I OTHER <br />l , <br />i <br />1e w k will be done In accordance with San Joaquin County. <br />r1 Local ealth District. <br />I � e <br />i <br />ENT USE ONLY <br />b <br />❑ January 1 & Received By -January 31 ❑ July 1 & ReceivedjBy July 31 <br />REMITTANCE $ AMOUNT DUE CHV <br />DATE REMITTED AMC <br />II �y <br />Received by . . . Wine , „�.,��r. - - , <br />`-- APPLICANT—RETURN ALL COPIES TO; - ENVIRONMENTAL HEALTH PERMITISERVICES <br />Issuance Dote Mailed Delivered <br />1601 E. HAZELTON AYE., P -Q, eOx 2009 STOCKTON, CA 95 <br />i <br />