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Applications Will Be Processed When Submitted Properlir ompleted. Be Sure To Sign The Application. <br /> OPLICATION <br /> a � <br /> (For Nan-Trrnslarabie,Revocable,and Suspendable) SEPTAGF <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application Is hereby made to carry on uamess,in the jurisdictional area of the an Joaquin Local Health Distri l <br /> business Name(DBA)L_E_E. I1_I_TH I Z h E, Address <br /> Owner LF E: W AC HI LA Address SN►1'1 <br /> cur Firm Partners, Addresses and eiephone Numbers <br /> ` Business Telephone No. �/ �, � — Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) F 6= Pk Title Cate - <br /> Please check Applicable Category 0-7y 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. ❑ PERCOLATION PEST <br /> R.S.or R.C.E.Name R.S.or R.C.E.No. <br /> Test Location Test DatelTime <br /> 4. ❑ SANITATION PE IT <br /> Job Add ILo Lion L-� <br /> Owner ; Address �� V()L <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY tNEW ` 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 /> Punt Capacity No. Units-Served <br /> 7. 0 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 ce have prepared this appiicatio and that the work will be done in accordance with San Joaquin County <br /> ordinances,state law ,a rut land eguE Ion o oa n Local Health District. <br /> APPLICANT'S SIGNATURE �'` <br /> _ t <br /> ) <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 d.Received By January 31 ❑ July 1 A Received 6y July 31 <br /> REMI <br /> BILLING REMITTANCE Z <br /> EASE EXPLANATION AMOUNTDATE REMITTED AMOUNT DUE CHE <br /> A M N1T� <br /> FEELl <br /> LESS �. <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by to Recelpt No. Permit No. nce a ■i ed Delivered <br /> APPLICANT—RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMWSERVICES 16131 E.HAZELTON AVE.,P.O.Bex 2M STOCKTON.CA 95201 <br />