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..yy......... .v ... ..c . ..ecnao.. .. c ouv.u. cu r vyc ) w Pc.oa. .+c s.. v v ..y . c ..rr••••••••••••• <br /> APPLICATION <br /> .,-or Non-Transferable, Revocable, and Suspend. <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to car on business in the jurisdictional area of the San oaquln Local Health Distrri�I <br /> IF Business Name(DBA) Z.., E-fi Address �erh % 9!: i2 <br /> iOwner Address <br /> Firm Partners, Addresses and Telephone N _ <br /> iBusiness Telephone No. S Emergency Telephone No. 1 <br /> Contractor Licence No. <br /> L Applicants Name (Print)— Title ,'A, ./E� Date <br /> Please check Applicable Category (1-7)and Fill in the llkq.iined 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. Liccnse 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 Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Add res Location O <br /> Owner a �G �- Address <br /> EPTIC TANK ❑ CESSPOOL RLCEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 13 NEW ❑ REPAIR ❑ OTHER d ` <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 Shy' <br /> Type Construction Disposal Site r� <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 FP <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 p <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 this a plication and that the work will be done in accordanceJo quip C�unty <br /> ordinances, state laws, and ruand re tions <br /> I the an quin Local Health District. <br /> APPLICANT'S SIGNATURE <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> /qr iv No, <br /> A. i.�byDate Ri5i No. Permit No. Iss alTnce�a Madel Dellvared <br /> ANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.B.2009 STOCKTON,CA%201 <br /> ((ZC J <br />