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Applications Will Be Processed When Submitted Properly Com <br /> APPLICATION pleted. Be Sure To Sign The Application <br /> (For Non-Transferable,,Revocable,and Suspendable) i <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the Sart Joaquin Local Health District <br /> O Business Name(DBA) 'D.A. PAAAt5L4 SC!mT, �A C , Addresses �<(1} <br /> rOwner Address <br /> 0 Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No.' ' � �1(�.0-7 Emergency Telephone No. <br /> -J Contractor Licence No. Sr- <br /> L Applicants Name (Print) y sz. _ Title T1l/�T©�` Date I — O <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., Color) <br /> Serial No. CAL. License No. CAL. Licznse Renewal No. <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 <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 _ <br /> c # Test Date/Time ' <br /> 4. &SANITATION PERMIT + <br /> Job Address/Location GHQ R'L <br /> Owner Address <br /> M SEPTIC TANK ❑ CESSPOOL. &LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 29PERMANENT ❑ TEMPORARY C$'�VEW ❑ REPAIR ❑ 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 /> F 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name - <br /> _ 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 /> F ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I ve prepare this application and that the work will be <br /> done in accordance with San Joaquin County <br /> ordinances, state law rules a regula - ns of a Sltfn Joaquin Local Health District. <br /> t < <br /> APPLICANT'S SIGNATURE <br /> 12 � FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING R MITTANCE $ REMIT <br /> BASE ,EXPLANATION ..E AMOUNT DUE CHECKED <br /> _ ; DATE ATE REMITTED <br /> { AMOUNT <br /> FEE �;.. � 9a r � <br /> LESS <br /> PRORATION <br /> I <br /> I a -,PLUS <br /> PENALTY"' <br /> t <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No.a Permit No. ssu ce Date Mailed .Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES'. 1601 E. I TON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> 3 <br />