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Applications Will Be Processed When Submitted Properly Completed. Be SureTOsign sneAppncanun. <br /> APPLiCAT10_N <br /> �F-- ' (For Non-Transferable;Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH,PERMIT <br /> LIQUID WASTE <br /> APA'pplication is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> T� l��o n 4eLt S `� Address,--°jq.22 . <br /> w Business Name (DBA)Alk PA - -r f �Y <br /> z Owner .. Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers - <br /> a (� �j"Z Emergency Telephone No. <br /> a Business Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) lI1�.S - Title �' Q Date Z—Z- <br /> -� <br /> Please check Applicable Category (1-7) and-Fill in the Required�Informatlon. <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> ( <br /> I For July 1;_June 30, 19 Disposal Sites - <br /> Description(Make/Yr., Color) # _ E , , ,,e y <br /> Serial No. CAL. License-No. CAL. License RenewlthNo. <br /> Capacity Gal., Weights &Measures No. , <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19'1— -4-, <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored t <br /> 3. ❑ PERCOLATION TEST ' t <br /> R.S.or R.C.E.Name ° R.-S,or R.C.E. No. _ <br /> _ 4t- <br /> • Test Location Test Date/Time <br /> 4. SANITATION PERMIT, V <br /> Job Address/Location Z L T <br /> Owner cA Address <br /> E] SEPTIC TANK 11 CESSPOOL LEACHWG FIELD SEEPAGE PIT `"❑'PACKAGE PLANT <br /> CKEERMANENT ❑ TEMPORARY ❑. NEW O'REPAIR �E14THER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction r Disposal Site s w, <br /> No. of Units Equipment Storage/Cleaning Location(s) „ eo <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> .t Where Certified r <br /> Operator Name :,, ( ' <br /> Plant Location - s <br /> Po.'Units Served } <br /> Plant Capacity 4 <br /> 7. ❑ LAUNDRY , For July 1, -June 30, 19 r _ <br /> SIZE: a ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> k <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 6 - <br /> ir <br /> I hereby certify that I h e prepared this applicati d tha a work will be done in accordance with San Joaquin County <br /> ordinances, state law d're lations o e Sa oa Lin L-ocdl.Health District.',_, � F <br /> APPLICANT'S SIGNATURE X - <br /> R#�$ - 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 T $ - <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> r DATE DATE REMITTED AMOUNT <br /> F - - ! � <br /> E£ <br /> LESS t r <br /> PRORATION { <br /> PLUS <br /> a <br /> PENALTY � �.}r � ,�, -�• - <br /> OTHER �^ <br /> OTHFR 1. t <br /> Ci by Date "-° =_r' „Receipt,No:, 3,a _ 'mrrnkt_NO. �,�, 4��ssuane Date " Mailed Delivered <br /> :.�! i.. <br /> AP (CANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITI5ERVICES STOCKTON,CA 95201 <br /> 1601 E.HAZELTON AVE.,'P.O.Box 2009 <br />