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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> { ENVIRONMENTAL HEALTH•PERMIT <br /> LIQUID WASTE <br /> Appl ationis hereby made to carry on business in the jurisdictional,area of the San Joaquin Local Health District <br /> F Business Name (DB1A4`)_ L�yD �� —Address <br /> aOwner Address 24 1 <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone� No, = Emergency Telephone No. <br /> 1 Contractor Licence No. , YS -& - <br /> LApplicants Name(Pint) Titley - Date "� Z <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> �k <br /> 1. 11 PUMPER VA ICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, OJune.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. S <br /> Equipment ParkingAddress <br /> 2. ❑ PUMPER YARD <br /> For July,1,_ 11 une 30, 19 <br /> No. of Vehicles St oAed <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATI�! N TEST, 1 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No, <br /> Test Location • �r Test Date/Time <br /> 4. A SANITATION PERMIT <br /> Job Address/Location L It. if 5-727 "J <br /> Owner— n9a& 1Yi Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL P(LEACHING FIELD I SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT I C3 TEMPORARY E] NEW REPAIR E] OTHER r <br /> 5. 11CHEMICAL. OILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment,Storage/Gleaning Location(s) . <br /> &. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 v ) <br /> Operator Name -Where Certified <br /> Plant Location <br /> Plant Capacity Ik No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -"June 30, 19 <br /> SIZE: ❑ Less Than'1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. } <br /> ❑ DRY CLEANIO Chemicals Used/Amount/Mo. 1persru-.Hoke auvner a :ic. e 1 A e; - ��rds�cn 'R,i ^'^:Sc,'ins "t r "n,:eofthewnrkforvihichchis permit is issued,I shall not employ� _ _Contractor's E;frsrp or s:k- r3 r'.:�-'iis :? ^=ar_;Y°^ ri; ;;.-'CMr;ig:,;;l CG illy `,x:.133 1115 perfCrflarca uitiu 4vork for vwiiir:i illspermltislssued,i <br /> employ p�erso ''SUijC2i ie W3f:MQ0,'5 L:WL t:l Ca'rBl4la," <br /> I fiereby!'certify that I tiave-prepared this applica ' and that the work will be done in accordance with San Joaquin Co <br /> ordinances, state laws, and rules and regulation of the S Joaquin Local Health District. �r0 �"tr <br /> APPLICANT'S SIGNATURE X 91- 4f-) <br /> Z7Q, <br /> + ! - FOR DEPARTMENT USE ONLY ell <br /> Fee Is Due: ID ANNUALLY ❑ PER UNIT 0 PER SITE ❑ EACH .❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> s -.. <br /> FFF BILLING REMITTANCE $ AMOUNT DUE REMIT <br /> BASE EXPLANATION CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE a s <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY da <br /> OTHER <br /> OTHER iF _ <br /> I l �4 3 a--- �- <br /> Received by �f Date Receipt No. r Permit No. - Is ante Dale Mailed Delivered <br /> APPLICANT FIETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES— 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201- <br />