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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ��2 0 <br /> APPLICATION <br /> or Non-Transferable, Revocable,and Suspendabl*W SEPTAGE h/'E-r T LEP <br /> ENVIROf9MENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to car on business in the jurisdictional area of th an oa u'inLocal Health District ,55 4e <br /> OF Business Name (DBA) . PJ Address <br /> a Owner_M?iNY Pit�Z2A Address, <br /> J Firm Partners, Addresses and Jelephone Numbers <br /> aBusiness Telephone No. � �`r/ Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) 7E71?,Y P/A= 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 /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License 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.�o Chemical Toilets Stored r <br /> 3. 9 PE LATION TEST <br /> R.S.or COName 7E:1z:F,Y V)b-Z .A R.S. or(DNo. <br /> Test Location <br /> 0774 I-. NWML- Rte■ Test Date/Time on <br /> 4. ❑ SANITATION PERMIT �i`� <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ 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. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared iS a (cation an hat the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rul a ations an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 'L QST 4L �5 . [ AUS � q-6aL-- <br /> 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 /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit Na. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />