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t4l,5. 2 g j APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTACF leDKEV,, <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made t,olcarry on business in the jurisdictional area of the Sa J aquin Local Health District <br /> Business Name (DBA) Plel&A P.�fIY_M-4_�__p/N1,� Address� w F-1 LA 5r- Livil, � <br /> Owner -tE?►rn�r 4,1p U Address-32'.:� E <br /> w. LS 4 ST-L.110 ftp <br /> j Firm Partners, Addresses and Tete hone Num <br /> bersg <br /> $� Business Telephone No. aro -row f Qi Emergency Telephone No._ il�'� �� 9¢ _ <br /> J Contractor Licence No. <br /> a Applicants Name(Print) !MPRY FILZZA —_ __- 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 of Chemical Toilets Stored <br /> 3. Id PERCOLATION TEST <br /> R.S_o<ffDName-TEAK" FWZ $ _ __ R.S. or6�NO. <br /> Test Location _ Test Date/Time <br /> 4. ❑ SANITATION PERMIT 4 r7( IC. 'T'IJRIJEI� , <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 __ PAYMENT _ <br /> 7. ❑ LAUNDRY For July 1. -June 30, 19 _ RECEWE D <br /> SIZE ❑ Less Than 1,000 Sq. Ft_ ❑ More Than 1,000 Sq. Ft. d � ���� <br /> Iltl <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. -- -- <br /> SDN JOAWIN GOON i Y <br /> PUBLIC HEALTH SERVK ES <br /> nn,•r� 1M1ipF[NIAl-H=.a_.TFi �IVkSION <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San JoaquinCounty <br /> ordinances, state laws, and rules a d ulations of the Sap Joaquin Local Health District. Q712Y� L fG�A <br /> APPLICANT'S SIGNATURE X <br /> 2 <br /> If <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 g REMIT <br /> BASE EXPLANATION AMOUNTDUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE CM <br /> LESS <br /> PRORATION <br /> PLUS -- - - <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Recewed by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Bo:2009 STOCKTON,CA 95201 <br />