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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> F (For Non-Transferable,`Revocable,and Suspendable) SEPTAGi <br /> ENVIRONMENTAL HEALTH PERMIT �( <br /> LIQUID WASTE 6 <br /> Application is hereby made to c r on bu ss in the j risdictional area of the an Joaquin L cal Health District <br /> F Business Name (DBA)L rm L.� � t ��' Address 35O <br /> I z Owner L Address <br /> Firm Partners, Addresses ar T lephone Numbers <br /> aBusiness Telephone Emergency Telephone No. <br /> a Contractor Licence No. <br /> Applicant Name`(PYint)` -�-- <br /> Title Y' ate <br /> Please check Applicable Category (1-7)and Fill In the Required Information <br /> 1. ❑ .PUMPER.VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For Julyj1` June 30, 19 t - -- Disposal Sites - <br /> Description(Make/Yr., Color) _ <br /> Serial No. 'CAL. License No. KCAL. License Renewal No. <br /> 'Capacity' G al.-Weig hts-&-Measures-No. <br /> s 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:-11-PERCOL-ATION-TEST-. —. .,.'^-y----------T--------• T- <br /> R.S.IF R.C.E. Name R.S:or R.C.E. No. ) <br /> TestlLocation ` t _` Test Date/Ti 1 <br /> 4. ID SANITATION PE Y. � <br /> Job Addr /L ( ) # <br /> - I <br /> St <br /> Owner c doI ?; Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHINGFIELD - �QRSEEPAGESPIT ❑ PACKAGE PLANT <br /> C3 d.ERMANENT 1:1TEMPORARY " NEW EPAIR E 0 OTHER Ott + <br /> i <br /> S. ❑ CHEMICAL TOILETS For July 1-�-Uur e 30, 19 <br /> is <br /> 1 <br /> Type Construction " Disposal,Site f <br /> 1E i 3 <br /> NO. of Units Equip`nent Storage/,Cleaning Location(s) € c <br /> 6r ❑ PACKAGE TREATMENT PLANT F_or July 1, -June 30, 19 tY l <br /> i ( Where Certified <br /> Operator Name <br /> Plant Location <br /> %Plant Capacity """- No. Units Served _ <br /> 7. 0 LAUNDRY For July 1, -June 30, 19 <br /> El:SIZE: ❑ Less Than 1,000 Sq. Ft.,. ❑ More Than 1,000 Sq.;Ft. <br /> ❑iiDRY CLEANING, Chemicals Used/Amount/Mo—_-C <br /> i 1 <br /> ! hereby certif ve prepared application and t i the work will tie done !,--accordance with San Joaquin County <br /> ordinances, sta a laws, an ales and regul tions o the.San vaqui Local Health District. <br /> APPOCANT'S SIGNATURE X <br /> 1 <br /> FOR DEPARTMENT USE ONLY j € <br /> Fee Is Due: 1:1ANNUALLY ❑ PER UNIT ❑ PER SITE 11 EACH; EI January 1 &Received By Uanuary 31 ❑ July 1 &Received 6y July 31 I <br /> - - y IT r <br /> BRSE EXPLANATION BILLING REMITTANCE f $ AMOUNT DUE CHECKED <br /> .. DATE DATE. I, REMITTED 'AMOUNT <br /> Y •I TEE hy <br /> ey- <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHERW_ r <br /> r - w <br /> OTHER j i <br /> fReceived by Date Receipt No. Permit No. .I { i .+ss r= te ail Delivered <br /> 'APPLICANT—RET IRICALL QOPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERV CES 1601 E.HAZELTON AYE„P. 2009 STOCKTON,CA_95201 <br /> i <br />