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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. / /� <br /> " APPLICATION G T <br /> ( 1pn-Transferable,Revocable,and Suspendabj. <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby/made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yr Business Name (DBA A.Z.�s. /L ---- 1 -- Address <br /> F­ <br /> Owner .1. �� ; Address <br /> 9 Firm Partners, Addresses and Tele hone Numbers <br /> Business Telephone N61_0z' 1� � Emergency Telephone No. <br /> Contractor Licence No. _ <br /> Applicants Name (Print) ✓C-G G/2. 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 bisposaf 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. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT // �// T I 9 <br /> Job Address/Location ' -- / ( ( <br /> Owner naN C-05 Gi— Address 27� <br /> O'SI=PTIC TANK ❑ CESSPOOL ' ' 0-LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 0 TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. 0 CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site _Jr_ <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. 0 LAUNDRY For July 1,-June 30, 19 <br /> SIZE; ❑ Less Than 1,000 Sq. Ft., - ❑ Moro Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <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 and reg a�tiioo9'-a of the Stan Joaquin Local Health District. <br /> APPLICANTS SIGNATURE x " <br /> r <br /> '4- <br /> FOR <br /> }FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 d Received By January 31 ❑ July 1 d Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE- CHECKED <br /> AMOUNT <br /> FEELESS <br /> p <br /> PRORATION ' o <br /> PLUS ,3 <br /> PENALTY <br /> OTHER .� <br /> OTHER. <br /> Received by Dale Receipt No Permit No. islue.ce Vale Mailea DCliverea <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />