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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION T <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby de to carry on business in the jurisdictional area of the San Joa5uin ocai Health District L <br /> rn Business Name (DBA) LZ 4 ��� Address ��oa �li.tl�2. STiZ:JL�" <br /> zOwner Address <br /> Firm Partners, Addresses and Telephone Numbers n) <br /> a Business Telephone No. � Emergency Telephone No. <br /> a _ <br /> 1 Contractor Licence No. ZS 4 <br /> LApplicants Name (Print) SMALlthy ��M S Title �Sr Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> t. ❑ 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. Licczse 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 I. Test Date/Time <br /> 4. S1 ANITATION PERMIT 11,l <br /> Job Address/Location Z 1 l 1 Z . �11�C 1C p 7.?E .' MA IrJ"T Cry !V <br /> O�wnn 1.1-,L-L. X14 h-) Address QI "PJJ EC <br /> L7 SEPTIC TANK 11CESSPOOL LEACHING FIELD aSEEPAGE PIT 11 PACKAGE PLANT s <br /> I rPERMANENT ❑ TEMPORARY M NEW ❑ REPAIR ❑ OTHER V#J <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 - U <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 /> Where Certified <br /> Operator Name <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. k <br /> I 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, a Liles and re lations o e S aquin Local Health District. w <br /> APPLICANT'S SIGNATURE X _ <br /> r � <br /> FOR DEPARTMENT USE ONLY t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE (] EACH ❑ January 1 &Received By January 31 a ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE ;�._ REMITTED AMOUNT <br /> PEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ! <br /> t <br /> F <br /> OTHER 4 <br /> OTHER <br /> Received by Date 1. Receipt No. Permit No. Iss ance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC%TON,CA 95201 i <br />