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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 /> Appllcati ¢y dP1 carry I thajurpdIctional area Of the S r�do�g�in L�pI I-1�aiy�gistriFt <br /> :usiness (DBA) <br /> bI ICS C. Ace .7:(Z tl rasa S/SIM /'Jl ( 11 �! Ave <br /> )wner M CAZGr1e Address _M <br /> irm Partners;Addres&es and TeI6gtlgn%NumDe " <br /> Wsiness Telephone No. as<< J Emergency Telephone NO. <br /> :ontrector LicenceNo. , <br /> ,pplicants Name(Print) _ Title Date <br /> Tease check Applicable Category (1-7)and Fill in the Required Information 1 ' <br /> ❑ PUMPER VE41CLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> or July 1, June 30, 19 Disposal Sites - S <br /> )ascription(Make/Yr.,Color) I r <br /> serial No. CAL. License No. CAL. License Renewal No. <br /> ;specify Gel.;Weights& Measures No. _ <br /> '.quipment Parking Address <br /> h�. PUMPER YARD or July 1, June 30, 19 <br /> Jo. of Vehicles Stored <br /> Jo.of Chemical Toilets Stored <br /> :.'`❑ PERCOLATION TEST <br /> I.S.or R.C.E.Name R.S.or R.C.E. No. 1 <br /> 'est Location Test Date/Time <br /> ❑ SANITATION PERMIT T ,Cp <br /> ob Address/Lo ation J ���' W i �w ART R o t\p .� <br /> )wner -TAVea !'gD RANCh� Address If S ntt4tiu <br /> THMe Rne LA71WA'P <br /> :1SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT V <br /> 7 PERMANENT ❑ TEMPORARY ❑ NEW 01 REPAIR Cl OTHER <br /> I. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 _ <br /> type Construction Disposal Site <br /> Jo. of Units Equipment Storage/Cleaning Location(s) <br /> 1. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> )perator Name _ Where Certified <br /> 11ant Location <br /> 'lent Capacity No.Units Served <br /> 1. ❑ LAUNDRY For July 1,-June 30, 19 <br /> ;IZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1.000 Sq. Ft. ' <br /> I DRY CLEANING,Chemicals Used/Amount/Mo. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,an les and rePgulatio`n/s�-of the Say(r/d�Joaquin Local Heafth District. <br /> 1PPLICANT'S SIGNATURE X '` ` " ._ .. <br /> FOR DEPARTMENT USE ONLY .1 <br /> Fee Is Due: ❑ ANNUALLY. ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 to July 1&Received By July 31 <br /> BILLING REMITTANCE E HE <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECK EDe- <br /> AMOUNT, <br /> FEE ` <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> eceived by ` to Recelpl NO.- rmn Issuane,Mite Ma,led Debvered <br /> APPOcANT—RETURN ALL COPIES TO: ENVIRONWNTAL IIMTH PERMT/SEAVICEa-. feel E.NAZELTON AVE.,P.O.boa leas STOCKTON,CA fsall„ <br /> i9AO&AG, Je-e-s8 I <br />