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x Applicationa.Will Be Processed When Submitted Properly Completed. Be SureTo SignTneAppucauon <br /> ..�` APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> y LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San.Joaquin Local Health District r <br /> .Address tocktori CA 95206 <br /> wrBusiness Name (DBA) 95205 <br /> ch <br /> r Address 038 -E. ,lash' ton Stockton, GA <br /> a Owner r - Wol i rte _ . , <br /> 1 Firm Partners, Addresses and Telephone Numbers )3rOWIl cas CaL�a a1 �� Machad0r Bud Bt15 <br /> �2n9 464-8361 Emergency Telephone No. l <br /> Ix Business Telephone No.f--. L R" } <br /> Contractor Licence No. _ .. Esti tOr �nate 06=28--M <br /> z m Canr7Ars Title H . . , <br /> L Applicants Name (Print) - .: v <br /> 1-7 and Fiil in the Required.Information r e >;� I3 a <br /> Please check Applicable Category ( ) _ _ t t <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30;19-'' - . w Disposal Sites - "- <br /> Description(Make/Yr.,Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> rCapacity _ Gal., Weights & Measures No. <br /> y iEquipment Parking Address — <br /> 2. <br /> - <br /> 2. ❑ PUMPER YARD ; <br /> k` For July 1, June 30, 19 - <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3, Ca PERCOLATION TEST - <br /> R.S. or R.C.E. Name _ A.S. or R.C.E. No. a <br /> TestLocationTest Date/Time <br /> 4. X/SANITATION PERMIT <br /> Job`Address/Location Avenue Stocktcn CA 95205 <br /> C�a1 Hol i negg Cht1rCh Address <br /> Owner� C4 .�-PACKAGE-PLANT_.y....-. - <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD WSEEPAGE PIT. <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ]REPAIR ❑ OTHER <br /> EY - <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> ,Type Construction a . Disposal Site <br /> ` No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENTgPLANT For,July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name' , <br /> Plant Location g <br /> ` Plant Capacity I No. Units Served <br /> 7. ❑ LAUNDRY -For July 1, -*'June 30, 19 :,I <br /> :SIZE: 13Less Than 1,000 Sq. Ft., 0 More Than1,000 Sq. Ft.11DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home owner or i:cerezod 7.t;cni•a signot�;re cartifosthpfallowing:1 certify tha.t1,thepertutmaaaen`the workfnrwbich alis permit is issuhall not employ any perso <br /> in such manner as to subject t„ :�o:€:r-:.:''.ci:rr_;pensatloniax'ofCal�'fulr...' <br /> Contractors hir:r�r o- Wt-cant: X,1' '.:: staiur, ,:r;ttitrss .+ -e3o:vi�ig. '€ce`tlt'!ihai i<i;hc perfvc,rar as of lila work for vfiliCh this permit is issued,t shall <br /> �4 employ persons subject <br /> g I hereby certify that I ve prepared ttiis application and that the work will be done in accordance with San Joaquin County <br /> ' Ordinances, state law_ d r es a regulations of the San Joaquin Local Health District. 7 , <br /> 'APPLICANT'S SIGNATURE X r <br /> J.T. Sanders <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 Jury 31 <br /> REMI7 <br /> BASE E%PLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE -:REMITTED. ;.. 'AMOUNT <br /> FEE <br /> �. <br /> LESS <br /> PRORATION <br /> PLUS ° y <br /> PENALTY . <br /> OTHER _ i - ...#-. <br /> OTHER <br /> ua e Date Mailed Delivered- <br /> Received by pate Receipt No. Permit No. <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT 1601 E. ON AVE..-P.O.Sox 2009 STOCKTON,CA 95201 Ca <br />