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nNNrrwnurra mrrr oe rrocessea wnen bubmitted Properly Completed. Be Sure To Sign The Application . <br /> APPLICATION <br /> (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 S�aquin Local Health District <br /> FBusiness Name (DBA ) 4 . oo``u L � �% Address • ©• etiL Ice re AW71<. A. <br /> a Owner . ,� 1- '� . zG �d 2_ Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> L Business Telephone No . / Emergency Telephone No . <br /> j Contractor Licence No . S � � <br /> L Applicants Name ( Print ) 1 e 16(z; R Title 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. Liccnse Renewal No. <br /> Capacity M. Gal . , Weights & Measures No. - <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD i <br /> For July 1 , June 30 , 19 <br /> No, of Vehicles Stored <br /> No . of Chemical Toilets Stored r - r�--�� • ''` ~ <br /> 3. ❑ PERCOLATION-TEST V <br /> _ <br /> R . S , or R , C , E. Name _ _ R.S . or R .C . E.�No , <br /> Test cation = Test Date/Time <br /> 4 . m SANITATION PERMIT r , <br /> Job Address/Location t i G Q <br /> �O,,wn � 6�/03 = Address . V -S 0 A 2 <br /> IR SEPTIC TANK ❑ CESSPOOL WeiLEACHING FIELD 0 S9EPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 15'kEPAiR ❑ OTHER <br /> S. © CHEMICAL TOILETS For July 11 - June 30 , 19 <br /> Type Construction Disposal Site <br /> No . of Units Equipment Storage/Cleaning Location ( s) <br /> 6 . El PACKAGE TREATMENT PLANT For July 1 , - June 30, 19000 <br /> Operator Name Where.Certified - - - - � U <br /> Plant Location <br /> a <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. %6 <br /> ❑ DRY CLEANING , Chemicals Used/Amount/ Mo . <br /> - <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 an a ions of the San Joaquin Local Health District. , <br /> APPLICANT' S SIGNATURE XAi <br /> ft ��L <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY OPER UNIT ❑ PER SITE V. ❑ EACH ❑ January 1 & Received By Jaguary 31 ❑ July 1 & Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> ,� DATE DATE REMITTED AMOUNT <br /> + t <br /> FEE J , <br /> LESS <br /> PRORATION . . . _ _ ,, . VI <br /> PLUS �� � �r . . 17 <br /> ` <br /> —PENALTY . . . V ma- <br /> OTHER 00 <br /> OTHER - i r' <br /> Vy " <br /> Received by Date Receipt No. F m , <br /> Permit Np. . Ince Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E. HAZELTON AVE., P.O. Boz 2009 STOCKTON, CA 9520 <br />