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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) <br /> ENVIRONMENTAL HEALTH PERMIT ,:. SEPTAGE �. <br /> e LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the S n Joaquin cal H pith District _ <br /> N Business Name (DBA) Y1 �z 19 P<hbe EC V3C'4 Address' i d �7 — <br /> a Owner S-fPLt'e L,_ 01Sa 1., Address VF• � Yi1C�J,�FI � <br /> L) Firm Partners, Addresses and Telephone Numbers S-14V1'1_ft _ LS7 4 V '! <br /> 6. Business Telephone No. 909 Emergency Telephone No. . 40~ 6 9 C1 4P. y <br /> Contractor Licence No. C L ';L-" 3 Z T977-7 <br /> Applicants Name (Print) .S' ry 2 Z �L�D 1.� _- - Title a'� V Date <br /> - ate- <br /> Please check Applicable Category (1-7) and Fill in the Required Information V1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, - June 30, 19Disposal Sites <br /> Description(Make/Yr., Color) 0 I"' % �-- } -� <br /> Serial No. CAL. License No- b CAL. Licc^se Renewal No. j <br /> Capacity Gal., Weights & Measures No. 9 <br /> Equipment Parking Address �' <br /> 2. '❑ PUMPER YARD ri <br /> For July 1, —June 30. 19" <br /> No. of Vehicles Sfored <br /> No. of Chemical oiiets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. ` <br /> Test Location `� Test Date/Time <br /> f.. <br /> 4. XSANITATION PERMIT � f <br /> Job Address/Locations ,, t � )Oixs`"` C Y� Jn @2CT <br /> Owner rn KeTAy-W-e'er Address e-� c <br /> I�SEPTIC TANK 11CESSPOOL LEACHING FIELD ElSEEPAGE PIT 1:1PACKAGE PLANT CQEwpsS— <br /> �SC7J�t31�� j> <br /> -E-) PERMANENT 13 TEMPORARY NEW ❑ REPAIR OTHER S"i,�Y►'}P ,. <br /> -IS. ❑ CHEMICAL TOILETS:.For July 1, -June 30, 19 <br /> ,-" €Type Construction _ _. Disposal Site _ <br /> No. of Units Eq lu pment Storage/Cleaning Location(s) <br /> 6. 11 PACKAGE TREATMENT PLANT For July 1, -,June 30, 19 r t rr, <br /> Operator Name Where Certified <br />^,,,Plant Location I # <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June-30"19 t'. l �""�J, <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. C <br /> ` '❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t r <br /> .- I hereby certify that I ha prepared this application and that the work will be done in acco fiance with San Joaquin County - .. <br /> ordinances, state laws, an rule and regulations f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT1; ary <br /> O Y m <br /> Fee IS Due: 11 ANNUALLY -❑ PER UNIT ❑ PER SITE ❑ EA 1 &Received By Jana y 31 ❑ July 1 &,Received By July 31 4 <br /> BILLING ITTANCE $ <br /> DATE DATE RFMIT�� �,�" REMIT <br /> BASE EXPLANATION AMOUNT DUE 5 CHECKED <br /> PATE GATE REMIT7Ep AMOUNT <br /> FEE / <br /> i <br /> LESS <br /> x ° <br /> PRORATION <br /> r <br /> PLUS <br /> PENALTY ` s <br /> OTHER r <br /> OTHER: <br /> Received by Date Receipt No. Permit No, Issuance Date Mailed IDelivered 4�4 <br /> 11 APPLICANT—RETURN ALL.COPIES.TO: ENVIRONMENTAL HEALTH,PERMIT/SERVICES. 1601 E.HAZELTON AVE.,P.O.BoK 2600 STOCKTON,CA M - <br /> • / .� i „ r--• <br /> * ° s�- <br />