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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. <br /> { } APPLICATION f' . <br /> ar n�i Transterable,Revocable,and Suspends U <br /> _ ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Y <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) A Z e Address 2-20 !-GAJ, <br /> Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. 41x'41 - 7 Emergency Telephone No. <br /> Contractor Licence No. 257,A-- .343 - <br /> Applicants Name (Print) 572AW°-E.I.i 8 '5sr./5k Title QST 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.,Color) <br /> Serial No. CAL. License No, CAL. Licc;se Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 N� <br /> No. of Vehicles Stored �1 <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. W <br /> Test LLoo ation Test Date/Time <br /> 4. u SANITATION PERMIT <br /> Job Addres /Location �S �• � <br /> • <br /> Owner <br /> LDO /tit�t/B.f/, Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL RLEACHING FIELD SEEPAGE IT ❑ PACKAGE PLANT <br /> E PERMANENT ❑ TEMPORARY ❑ NEW 2 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 /> 6. ❑ 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. Pit <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> p <br /> I hereby certify that I have prepared this application that the work will be done in accordance with San Joaquin C unty <br /> ordinances, stat r a reg 11 ns of Sa oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 11 EACH 13 January 1 Rec ved By January 31 ❑ July 1 &Received By July 31 - <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> PATE DAT REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> OS7�3 v�3 0 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Deliver <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK ON,CA 9 201 <br />