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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) SEPTAL('_ <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE • <br /> w Application Is here y mada�to carry on business in the jurisdictional area of San J�aquin Lo_ca Health District <br /> ! r 1 <br /> ti Business Name (DBA)A / I -- Address • <br /> 'owner L c �� 20 6CTi Address '"� L r L `/ r <br /> J Firm Partners, Addresses and,Telephone Nlbers ' ` ' n/ �" <br /> a Business Telephone No.4?_ ye iy111s Emergency Telephone No. <br /> a <br /> Contractor Licence No. _ _ <br /> L Applicants Name (Print) �Lrt, N/ +✓ ')y6 t ��' ,if Title 1-Al '- Date �/ ' 9 <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. -M-PERCOLATION�EN ST ,,/ <br /> R.S. or R.C.E. Name _) !V ZZ/' R.S. or R.0 E. No. <br /> Test Location " Testj�ate/T�iim�e/� 4'C1 - t <br /> 4. 11 SANITATION PERMIT ✓ � <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 this application and thark will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulati ns of he an;4�'wo <br /> Local I_th District. / / ,Q <br /> APPLICANT'S SIGNATURE X _- f C �. C l ��' <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 /> Received 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.Box 2009 STOCKTON,CA 95201 <br />