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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> f t• I.5�92 �. APPLICATION' * 92 2D <br /> For Non-Transferable,Revocable,and Suspendab W SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT LF—UF—W'-.,�J I <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the�Sa�n J/Q,aq��u��i//n Local Health District 1 <br /> Business Name (DBA)EJ! �)hsde!LC_H � 910-ZZA Address _I 5 W EU-A =-1,Z. �524G <br /> Owner T'E'RRY 21NZ _A Address 3�}2�J W, E<Lt✓1 T=�,�J�ys�!a. 9524-0 <br /> j Firm Partners, Addresses and Telephone Numbers �D <br /> Business Telephone No. _-3�� �41l�.-�7! Emergency Telephone No. 4- <br /> Contractor Licence No. <br /> t Applicants Name (Print) 'TV_-_R1Z-Y ?1,&-Z 7-A _ Title C. Date <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. Rf PERCOLATION TEST <br /> R.S. orCEDName 7TERR,-� PIb7-z4 R.S.or .C.E No. <br /> trv9 j� P�LT1 '�L_ SV, Test Date/Time v <br /> Test Location ! <br /> 4. ❑ 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 th' pplication an hat th work will be done in accordance with San Joaquin County <br /> ordinances, state laws, d ru a gulations of t San Jo uin Local Health District. (` <br /> APPLICANT'S SIGNA'T'URE X <br /> 12 i E 7— NOL p PdRC.ELr -ZFOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 0 EACH ❑ January 1 &Received By January 31 ❑ July t &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMIT <br /> [� y AMOUNT <br /> FEE (� L� 2)L.vA t"v. �� ���g� 1-. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER l y� <br /> 6� <br /> a,wilved by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> i' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boy 2009 STOCKTON,CA 96201 <br />