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Applications Will Bel Pro essed When Submitted Properly <br /> o <br /> APPLICATION <br /> (For Non-Transferable, Revoce a <br /> ablnd Suspendable) SEPTAGE <br /> ✓' ENVIRONMENTAL HEALTWPERMIT �f <br /> LIQUID-WASTE <br /> Application is hereby made•to carry on-business in the jurisdictional area of the San Joaquin Local Health District <br /> 'Address <br /> w Business Name (DBA) - <br /> z Owner <br /> Address o.. Y.. . . <br /> a — --�• _ . <br /> Firm Partners, Addresses and Telephone Wumbers <br /> Emergency Telephone No. <br /> aBusiness Telephone No. Y - - <br /> Contractor licence No. F Dat p <br /> �Tltle _ flsq�g e <br /> Applicants Name (Print) <br /> Please check Applicable Category (1 7)-and.fill in the Requiredanformation ., fL ; �y ; {,1 ;,�(; �;3 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> - � <br /> For duly 1, -- � June 30, 19 ''Dis!� posal Sites <br /> Description(Make/Yr., Color) ICAL. License Renewal No. <br /> Serial No. If! "'CAL, License No. <br /> Capacity Gal.1,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD' <br /> For July 1, <br /> June 30, 19 n � <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name a 'k - <br /> Test Location IM Test Date/Time <br /> I .-_... -...• <br /> 4. ❑ SANITATION PERMIT ) <br /> Job Addres Location <br /> a <br /> � Address <br /> Owner = '. <br /> SEPTIC TANK 01 ESS L LEACHING FIELD '❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑\PERMANENT El EMP EWi L C1 REPAIR 11 OTHER. 1 <br /> 5, 13 CHEMICALTOILETS For July 1,-June 30,19 ---- <br /> Type Construction - ,11 . �-Disposal Site <br /> No. of Units IEquipment Storage/Cleaning Location(s) <br /> } <br /> g. ❑ PACKAGE TREATMENT PLANT For July 1,=June 30, 19 rIK l <br /> `1`� �- .. {_ Where-Certified_. <br /> Operator Name <br /> 'Plant Location } ° <br /> 1 - r No Units, erved <br /> I Plant Capacity t` rV <br /> is x fi - <br /> 7. ❑ LAUNDRY . For July 1,.-.June 30, 19 - <br /> `�❑ More <br /> SIZE: 0 Less Than 1,000 Sq. Ft., II° - v Than 1.,000 Sq' Ft.4). <br /> _ '. .. Yr - t. -�• -s <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> - I L ! <br /> I hereby certify that I haveprepared this application and that the.work will be done in accordance with San'Joaquin County <br /> ordinances, state laws, d s and regul ns of the San rJo qup Local Health District. <br /> or <br /> l I <br /> APPLICANT'S SIGNATURE X �. _ - r.,- -- Y <br /> 1 FOR DEPARTMENT USE ONLY <br /> - -- <br /> .� -, <br /> By <br /> + Feels Due: ❑ ANNUALLY _❑.IPER UNITE ❑ PER SITE ❑ EACH' ❑ January 1 &Received Ry January 31 - ❑ July 1 8 Receiv REMIT <br /> uIy-31 <br /> BASE EXPLANATION BILLING + REMITTANCE r $ AMOUNT-DUE CHECKED <br /> "']]] DATE .-} DATE REMITTED AMOUNT <br /> -FEE �$- `r+ Il°. { _ - <br /> LESS Y "1' - <br /> 'PRORATION P - - <br /> yyy 1 . <br /> PLUS - <br /> PENALTY <br /> OTHER <br /> t <br /> OTHER : <br /> Is uanc a Mailed Delivered <br /> Date 1i ;Receipt No. Permit No. - . <br /> ` Received by F"' - ZELTON AYE.,P.O.Box 2oo9 STOCKTON,CA 95201 <br /> APPLICANT-RETURN ALL COPIES'-O: ENVIRONMENTAL HEALTH PERMITlSERVICES "'1601 E.HA — <br />