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Applications W611 Be Proces�&d When Submitted Properly Completed. Be Sure To Sign"The Application. <br /> APPLICATION f <br /> .(For Non-Transferable, Revocable,and Su spendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatio I e by ma to cappyo business in the jurisdictional area of the San Joaquin Local Health Distrl t <br /> H Business Name {DBA) Address `7a - ��� ����•' j <br /> f' z Owner // Zoe Address <br /> a l <br /> G j Firm Partners, Addresses and Telephone Numbers <br /> RL' Business Telephone No. Z Emergency Telephone No. _ <br /> Contractor Licence No. <br /> L Applicants Name (Print) t Title S� 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, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Calor) <br /> Serial No. _ CAL. License No. CAL. License Renewal No. <br /> L. <br />( Capacity 'GalwWeights &Measures No. <br /> Equipment Parking Address _ <br /> I 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 Oso f t <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 /> .I <br /> Test Location Test Date/Time A <br /> 4. 0 1SANITATION PERMIT <br /> Job Address/Lo ti _ a <br /> Owner ;C �..�i+JA.r/ �� � Address � � <br /> ❑ SEPTIC TANK ❑ CESSPOOL P114,EACHING FIELD ❑, //SEEPAGE PIT ❑ PACKAGE PLANT <br /> I�ERMANENT ❑ TEMPORARY A NEW 04EPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> 1 Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) �o <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> Operator Name Where Certified <br /> F Plant Locatiorit_ -' <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 have pared thi plication and that the work will be done in accordance with San Joaquin County (� , <br /> ordinances, state laws, r s d gul ions the Sa oaquin Local Health District. - <br /> APPLICANT'S SIGNATURE X <br /> ce <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER NIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> f BILLING REMITTANCE $ REMIT <br /> BASE _ EXPLANATION .,AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS 1 f2 j- <br /> PRORATION -1 J1f <br /> PLUS .. <br /> PENALTY <br /> f OTHER <br /> t OTHER <br /> br 1 'g L3 0 <br /> Received by Date Receipt No Permit No. --ISSuan a Date Mailed Delivered". <br /> _ APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,PO R—2069 STOCKTON,CA <br /> r <br />