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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> F <br /> (For Non-Transferable, Revocable, and Suspendable) SEI'TAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is her y made to c rry on bu iness in the jurisdictional area of the an Joaquin Local Health District <br /> Business Name (DBA) P A XAA Z� � Address. /V Sd 57/L'� 911,o <br /> z Owner Address _ <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No._ 54 '9G-07 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) ST Title �Y�� Date jar 7^ V <br /> Please check Applicable Category (1-7) and Fill in the Required Information G <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 /> I No. of Chemical Toilets Stored <br /> 133. PERCOLATION TEST <br /> t. R.S. or R.C.E. Name R.S. or R.C.E.No. <br /> Test Loc ion Test Date/Time <br /> 4. Isz SANITATION PERMIT <br /> t Job Addre L cat! n Q <br /> CA A22� <br /> Ownsea Zak Address�� p <br /> t I,�� SSEPTIC TANK ❑ CESSPOOL �, LEACHING FIELD lr SEEPAGE PIT ❑ PACKAGE PLANT C <br /> 12 -ERMANENT ❑ TEMPORARY 2 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 /> t 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 \ <br /> Operator Name Where Certified <br /> Plant Location <br /> c Plant Capacity No. Units Served ' t <br /> c 7. ❑ LAUNDRY For July 1, -June 30, 19 I `o <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000-Sq. Ft. C <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo... <br /> f <br /> 1 hereby certify that I have prepared this application an <br /> I that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, d rules a regulatio f theJoaquin Local Health District. <br /> APPLICANT'S SIGNATURE X _.. <br /> c �J <br /> rt. FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY' ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 3 ❑ 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 /> C- <br /> LESS '1 yu !/(��/ <br /> PRORATION f� <br /> r <br /> PLUS <br /> PENALTY " <br /> OTHER <br /> OTHER <br /> J1rs- 1 - kd-w <br /> Received by _ Date Receipt No. Permit NO., - Issuance D Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITLSERVICES 1601 E.HAZELT P.O.Box 2009 'STOCKTON,CA 95201 <br />