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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 hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> t Cn <br /> r Business Name(DBA)fel•Ic }C_T,—ig k a jR 4rAqi Address <br /> , <br /> I- <br /> Owner AFV i�7N, �j'_A1b='tom. Address�1,73{� �Y t <br /> J Firm Partners, Addresses and Telephone Numbers <br /> 0. Business Telephone No. � d 73 Emergency Telephone No. <br /> Contractor Licence No. S <br /> I LApplicants Name (Print) Title Date _ <br /> Please check Applicable Category(1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> k' For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No, CAL. Ucz ruse Renewal No. <br /> k�k Capacity Gal., Weights & Measures No. <br /> I Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> k No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> r 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. 3 SANITATION PERMIT <br /> Job Addre ocation ' <br /> Owner r d.L1z sv .a ea,-+ Address213-ae o.C.II!.oz oG Lv u.� <br /> IZI SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW I$I REPAIR ❑ OTHER (� " <br /> ►' 5. ❑ CHEMICAL TOILETS For July t, -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,'16 <br /> Operator Name Where Certified <br /> Plant Location l <br /> Plant Capacity No. Units Served I <br /> 7. ❑ LAUNDRY For July 1, 'June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. �f <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. i Y <br /> L <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, statelaws, and r les and regulations the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> I . <br /> t <br /> FOR DEPARTMENT USE ONLY if <br /> Fee IS Due:-❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑-EACH ❑ January 1 &Received By January 31 - ❑ July 1 &Received By July 31 <br /> T <br /> BILLING REMITTANCE $ REMI <br /> BASEEXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE O S <br /> LESS a <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER <br /> k1417, V, l /� �o 6 ovy?�� <br /> ' Received by ate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> y <br /> - _ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.-HAZELTON AVE.,F.O.'Box 2009 STOCKTON,CA 95207 <br />