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F Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,'and Suspendable) f <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE:.. <br /> Application is hereby made to carry on business int e.lurisdictional area of the San J aquin Local Health- (strict. <br /> Business Name (DBA) Liz r- VAIN\,_�Z Add.--- ( <br /> aOwner - � <-- Address " nJ <br /> Firm Partners, Addresses an Tel Numbers <br /> aa. Business Telephone No. � T(� Emergency Telephone No. - <br /> Contractor Licence No. S _ <br /> a Applicants Name (Print} L k Title' <br /> L k .ra•,' ~` '. i rL�i T; e . • sy , 1 43 .:: <br /> Please check Applicable Category.(1-T)and Fill In the Required Information <br /> 1. '0,.PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ',t3j }"'� 'vy��� { # � <br /> For July 1, June 30,19. _ V : -y- ;;Disposal Sites,- <br /> Description(Make/Yr., Color) <br /> r' -Serial No. CAL. License No.', . ~' - .:,CAL.-License Renewal No. <br /> -'Capacity---- - - ;4Gal-, Weights-&•Measures-No.---- -- - - --- — <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> r <br /> For July 1, June 30, 19 - <br /> No. of Vehicles Stored <br /> I No. of Chemical Toilets Stored <br /> 3. ❑-PERCQLATIONTEST <br /> k d <br /> R.S.'or R.C.E. Name R.S.or R.C.E.No. <br /> Test}Location st Date/Time <br /> 4. 1:1-SANITATION PERMIT, <br /> Job 1Address/Lgcation 1= <br />` Owner " i�l ";, Address <br /> ❑ SEPTIC TANK'F ❑ CESSPOOL LEACHING FEELD_- [r EEPAGE PIT ❑ PACKAGE PLANT' <br /> ❑ PERMANENT 13TEMPORARY ❑'NEW �REPAIR ❑ OTHER <br /> l 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> ,Type{Construction' Dispos'l.Site <br /> +No. <br /> of Units Equipment Storage/Cleariing Location(s) <br /> = f f <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1;-June 30,"19"'` <br /> i I t <br /> a Operator Name t Where Certified i <br /> Plant Location <br /> Plant Capacity Tµ P No. Units Served <br /> LAUNDRY For July 1, -June 30, 19 I <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.., ❑ More Than 1,000 Sq. Ft. , <br /> ❑ DRY CLEANING;Chemicals Used/Amount/Mo. <br /> .� <br /> I hereby c ify tha ave preparekthis pplication and t at the,wnfk will be done i)-accord ince with San Joaquin County - ► -. -. <br /> Aq <br /> ordinances tate laws an san �tians othe San iOa uin oca ealth Distr+ct. c , <br /> -APPLICANT'S SIGNATURE _ <br /> FOR'DEPART.MENT USE ONLY <br /> Fee Is Due: ElANNUALLY } ❑ PER UNIT ❑ PER SITE,.ta. ,❑ EACH T3 January 1 &Received By January 31 © July 1 8 Received By July 31 ` <br /> .-..;,�."__,;- REMIT ' <br /> ' BASE EXPLANATION q�BILLING F REMITTANCE r$ r AMOUNT DUE CLIECKE�— <br /> t <br /> -_ DATE. DATE REMITTED - _ AMOUNT- <br /> FEE <br /> LESS <br /> `..PRORATION ,.I - <br /> ' PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by I pate I Receipt No. 1 ; _Permit No. . Issuance Date Mailed Delivered ! <br /> -APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES +' '- -1601 E.HAZELTON AVE,'P.O.Dox 2009 -STOCKTON,CA,95201 <br /> r; , <br />