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Applications Will Be Processed When Submitted Property 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 /> Appl icatio her y e to carry o us ne In the jun Ictional area of th qwn c ealthrDisArict C r <br /> Business Name (DBA) r C 14 Address— . -1�+ . C-. GC�l <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone( uumbers <br /> Business Telephone No. 466 -! i 07 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title 2�677 Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information f n <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites n <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. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. �. <br /> Test cation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location 12J70 SP <br /> Owner Address Fit0 <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($) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> H <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. Q 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 /> hereby certify that I have prepared this application and that the work will be done in accordannwithSanNly <br /> ordinances, state laws, and les and regul tions of n yea Local Health District. <br /> APPLICANT'S SIGNATURE X 1 8 1 el I <br /> L�k� 06- C/ <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT ' <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DAMOUNT DUE CHECKED <br /> ATE DATE REMITTED <br /> / AMOUNT <br /> FEE "C <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. 4ssuance Date Med Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT!$EgYIGE$ 1601 E.HAZELTON AVE.,P.O.Sox 9 STOCKTON,CA 95201 <br />