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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) SEPTAGF <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District- <br /> EB usi ness <br /> istrictBusiness Name.( A) . Address <br /> I Owner Fyddres ZQ 2 <br /> Aon Partners, Addresses and Telephones umbers (p <br /> c <br /> IL Business Telephone No. `1 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) e Title- Date - <br /> Please check Applicable Category(1-7) and Fill in the Required,Information <br /> ❑,PUMPER VEH#CLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,T June 30, 19- —. _ Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. r CAL. License No. CAL. License Renewal No. <br /> Capacity t Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD ' <br /> For July 1, June 30, 19 r <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 Location Test Date/Time <br />�4. ❑ SANITATION PERMIT _ j <br /> �a _ , �wi i ! inztq � � tawh S T�erh� <br /> — Job Addre / oa ion _ <br /> Owner -"Address 2 Z�l <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING'FIELD ❑ SEEPAGE PIT_ ❑ PACKAGE PL NT <br /> ❑ PERMANENT 13 TEMPORARY 13 NEW PAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,--June 30,'19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> S. ❑ 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. O <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I hereby certify thaAprepared lication and that thew rk will-be done in accordance with San4,A9jn,,.;oU�ntyordinances„state lans� a E a#'f:J aqui offal kfealth_Di 'riot .�-k+. J }c ;-`PPLICANT;S�SIGNATURE �� .:�!- - -r-.�., -•cam ,; �. ,yaw -�, s. . ,s•4... . <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EAC14 ❑ January t &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATIION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS N i I <br /> PENALTY <br /> r <br /> OTHER <br /> OTHER <br /> Received by I Date I Receipt No. Permit No. Issuance Date Mailed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2008 STOCKTON,CA 95201 <br />