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Applications Will Be Processed When Submitted Properly Completed. Be SurTo Sign The Applic tion. 2 .r� i <br /> APPLICATION Ict / <br /> I Ion-Transferable,Revocable, and Suspendabl <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made carry on business in the jurisdictional area of the Sa aquin_Local Health District A <br /> mBusiness Name (013,A)t �A .144: .C.0 Address" 'd <br /> OwnerA�.a� �J-L.L.��li !� Address — <br /> Firm Partners, Addresses and Telephone Numbe <br /> E. Business Telephone No. 1` 's Emergency Telephone No. <br /> � — <br /> Applicator Licence _ — <br /> �Applicants Name (Print) �—«� " , Title Date <br /> Please check Applicable Category(1-7)and Fill in the Requirod 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. Liicnse Renewal No. 7 <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 v <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 Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT _ ' <br /> Job Address/Location _ '`� s��tir /,P /���� <br /> Owner -�L"' Address ���_� ? TrA� - <br /> a-51 PTIC TANK ❑ CESSPOOL 0-nACHING FIELD ❑ SEEPAGE PIT 1-PACKAGE ANT <br /> ❑PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June$0, 19 <br /> Type Construction _ Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 0.' ❑ 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. j <br /> 1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and re tali f the Sa aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: D ANNUALLY ❑ PER UNIT - D PER SITE I•� ❑ EACH ❑ January 1 8 Received By January 31 D July 1 6 Received By July 31 <br /> REMIT <br /> B14LING . REMITTANC S <br /> BASE EXPLANATION - DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ' G <br /> PLUS O <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No, Permit No InuancoF ate Mailed Delivered <br /> 'APPLICANT—RETURN ALL COPIES TO: 1 ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boe]009 STOCKTON.CA 95"1 <br /> . t <br />