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Applications Will Be Processed When Submitted Properly Comp <br /> APPLICATION leted. Be Sure To Sign The Application, <br /> (For Non-Transferable, Revocable, and Suspendable) ` <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is here y made to car on business in the jurisdictional-area of the an Joaquin Local Health District <br /> [-Business Name (DBA) �.Y4- 1� S .-�AA1Sd <br /> Address g AZO <br /> a Owner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No.— �4 9GeV"7 <br /> Emergency Telephone N <br /> f Contractor Licence No. [� ne o. <br /> L Applicants Name (Print) <br /> Title � Zl�.�� Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information 7 <br /> t 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) O� <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> t Serial No. CAL. License No. <br /> [ Capacity CAL License Renewal No. <br /> Gal., Weights i£Measures No, <br /> III Equipment Parking Address <br /> 2. ❑ PUMPER YARD M.. '.. <br /> For July 1, June 30, 19 <br /> 1. No. of Vehicles Stored <br /> I No. of Chemical Toilets Stored I <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. t <br /> Test Loc on Test Date/Time - <br /> 4. SANITATION PEN`---RM <br /> ERMIT <br /> r Job Address/Location 107-11V <br /> s Owner ( Address <br /> ®EPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT —~ <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW E REPAIR 0-106THER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -ttJune 30, 19 ,r�,v� <br />{ Type Construction F" 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 1 <br /> Plant Capacity <br /> % _ No. Units Served <br /> 7. ElLAUNDRY For July 1, -June 30', 1-9 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., El More Than 1,000 Sq. Ft. Y <br /> ❑ t}RY CLEANING; Chemicals Used/Amouht/Mo. - g <br /> I hereby certify that I hav repared this application and that-the work will be done in accordance with San Joaquin Count <br /> ordinances, state laws, nd ulations e Sa que Local Health District. y <br /> APPLICANT'S SIGNATURE X <br /> r FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE. ❑ EACH <br /> ❑ January 1 &Received 8y January 31 ❑ July 1 8 Received By July 31 <br /> i <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> t DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION j•: <br /> PLUS <br /> PENALTY <br /> 3 <br /> OTHER - - - <br /> OTHER <br /> Received by Date 01-7 <br /> �3 IZ - I <br /> I Receipt No. Permit No. Issuance Date Mailed } <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES D red <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952D1 <br />