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App ations Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> �- )_ APPLICATION <br /> F, r <br /> qz (For Non-Transferable, Revocable, and Suspendable) <br /> ( ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local H lth District <br /> ,F, Business Name (DBA) I /7`i7 /C r y D' S� + Address Ga <br /> o 02 �v a- � ui'>, ,//'/ - <br /> aOwner f' z�f 1 d s7 Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. S_a a Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Z2/�< A4 .'-44 C2119 1z Title T✓7 �� Date q' �)r <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 r" <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. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> CAE SANITATION PERMIT <br /> Job Address/Location �— <br /> Owner IS- Z2G/Z S C / Address 10/ '� '" R - 6 <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW "gIREPAIR ❑ 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. f� <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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, and rules and regulations the San oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X l7 <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 MITTED AMOUNT <br /> FEE � � <br /> LESS <br /> PRORATION <br /> PLUS 9� <br /> PENALTY <br /> OTHER IF <br /> OTHER <br /> Received by Date Receipt No. Permit No. I suance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />