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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign,The Application. <br /> APPLICATION ' S. • .' <br /> ' (For Non-Transferable, Revocable,and Suspendable) r j SEPTAGE �` i <br /> ` ENVIRONM_ ENTAL HEALT,H.P.ERMIT J � <br /> LIQUID WASTE -t € -"4 ' F N <br /> Application is hereby made to carry on business in the jurisdictional area of the.San.Joaquin.Local Health District, t ,, <br /> H Business Name (DBA�'t_D A.PARRiSI45: n&9�J3AZC' �Addressp©•Fok <br /> z Owner. 3 .= Address . <br /> Firm Partners, Addresses and Tele hone Numbers - <br /> H. Business"Telephone"No. <br /> �� " Emergency Telephone No.V <br /> Contractor Licence No. <br /> Applicants Name (Print) ��ThJ`SL� std Title ��f_-> d Date <br /> Please check Applicable Category.(1-7) and Fill in the Required Information y `V .}6 .�, <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> r Description(Make/Yr.,Color) .;- � �`� •" 11 <br /> Serial No _ v CAL. LicenseLicense,Renewal'No. <br /> w. ..»_s, <br /> Capacity( `�•- Gal.,Weights &Measures No. <br /> Equipment Parking Address - <br /> 2. ❑ PUMPER YARD <br /> For July ), June 30,-"19 _- <br /> No. of Vehicies Storeda + <br /> No. of Chemical Toilets Stored ``- Z1 <br /> 3. ❑ PERCOLATION TEST !' yF <br /> R.S. or R.yC.E.-Jame # $�' s R.S.or R.C.E.c No. <br /> Testi Loc 'on tbI Test Date/Time <br /> 4. L?SANITATION PERMIT <br /> Job Address/Location oo 'T`r1� -'• 4 <br /> I 'Owner t�FQ-T��' [ 1�3Z Lam=-:Z - Address Sl�h`1 k 1 <br /> ❑ SEPTIC TANK ❑ CESSPOO12 EACHING FIELD •S•B—S.EEPAGE RIT ❑ PACKAGE PLANT: - <br /> CIPERMANENT " ❑ TEMPORARY ❑ NEWREPAIR ❑ OTHER j <br /> 5. ❑ CHEM#CAL TOILETS For July 1,-June 30,1 19 ^? <br /> Type Construction a e . Disp'osal Site r 1—N - (� <br /> No, of Units f Equipment Storage/Ckeaning Location(s) . <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator'Name Where Certified= <br /> Plant Location <br /> Plant Capacity <br /> i"�'"" NogUnits Served * t <br /> -7. ❑ LAUNDRY For July 1.1 -June 30, 19 y <br /> SIZE: �❑lless Than 1,000 Sq* Ft.,! ❑ More Than 1,000 Sq. Ft. <br /> ❑-DRY CLEANING,Chemicals Used%AmounVMo.. r <br /> r i <br /> . f . x <br /> I.hereby certify that prepared this applicationkc! that th ork will be done in'accordahce with San Joaquin County <br /> ordinances;`'state laws 5 and r ulations of San J qu" Loc Health District. , <br /> 1 <br /> APPLICANT'S SIGNATOR"X <br /> t l sr ©/ <br /> FOR DEPARTMENT.USE ONLY:i <br /> i Fee IS,DuL-- ❑ ANNUALLY : ❑ PER UNIT.' ❑ PER SITE.,., ❑:EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juty 31 <br /> $ _ r - _ I REMIT <br /> BASE - - r EXPLANATIONS BILLING REMITTANCE $ <br /> AMOUNT DUE CHECKED <br /> ' DATE 'F DATE REMITTED AMOUNT <br /> Z w42, <br /> FEE -.F 1:. Cca <br /> LESS } <br /> PRORATIONPLUS <br /> a <br /> PENALTY "^ i/tJk.� �" 3 '9>_ <br /> OTHER <br /> OTHER„� _ •-»,t.--..�.seo--�.`..... . _.�--"..-...-..-«www y.�..,�.a..«..-wd'- ..j-v.::�-:.r.�.r.ca+..:. .�-.aek..-a -......,_r.,Y. .. <br /> a. <br /> Received by Date Receipt No: Permit No.. ; - - - ance Date Mailed Deliver d _ - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES '` 16dit.tLKZELTON AVE.,P.O.Boli 2009 STOCKTON,CA 95201 <br />