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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION - <br /> r/1 (For Non-Transferable, Revocable,'and Suspendable) SEPTAGF <br /> 33 � I ENVIRONMENTAL HEALTH PERMIT <br /> " LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Lopal Health District <br /> F Business Name (DBA)-L—E- �1�1�_�� �u_ Z6C 11 :nP Address, :5� 0 LA ' CT j <br /> z Owner.� F _� W IRI- Ll.� Address <br /> d — -. ,. ,L, - <br /> J Firm Partners, Addresses and(`�elephone Numbers <br /> aBusiness Telephone No. - �a .� (11 4_1 Emergency Telephone No. <br /> Contractor Licence No. C <br /> L Applicants-Name'(Print) Lr N f t Pt t_ 'i t� Title. Z-Qate %3" �d <br /> Please check Applicable Category (117)and Fill in.the Required Information, <br /> 1. ❑ PUMPER,VEHICLEPERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, T- June 30,1-19.-_. ... ._ .- Disposal Sites - - - - - <br /> Description(Make/Yr., Color) <br /> Serial Na CAL. License No. CAL. License Renewal No. <br /> Capacity-- GaI -Weights &-Measures'No:-- -- • --` -- -�- <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD QQ <br /> For July 1, June 30, 19 ! <br /> No.pf Vehicles Stored <br /> •'No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST V <br /> 'R.S. or R.C.E. Name R.S. or R.C.E. No. i <br /> Test'Location Test Date/Time r e <br /> 4. ❑ SANITATION PER IT -�----Y E <br /> Job Address/Location -59 WO OL <br /> Owner _R pu-k"I C����p 1 � <br /> D ", Address <br /> �f SEPTIC TANK ❑ CESSPOOL 'Cl LEACHING FIELD `SEEPAGE PIT ❑ PACKAGE P_LANT I <br /> ❑ PERMANENT 11 TEMPORARY NEW ❑ REPAIR ❑ OTHER 'f s <br /> 5. ❑ CHEMICAL TOILETS For July 1, June 30, 19 i 'r• 4{ <br /> Type Construction } Disposal Site I t <br /> No..of Units Equipment Storage/Cleaning Location(s). l• �. <br /> '.5. 11PACKAGE TREATMtNT PLANT_. Forbly 1, -June 30, 19 Y s R <br /> Operator Name Where Certified 3 <br /> �. yr <br /> Plant Location : . <br /> Plant Capacity 7 y, 'e. f No. Units Served r <br /> 7.11-0 LAUNDRY For July 1, -'June 30,.19-; "' 1 4�' t _ <br /> 5IZL ❑ Less Than 1,000 Sq. Ft,; ❑ More Than 1,000 Sq. Ft. - <br /> ❑ DRY CLEANING, Chemicals Used/Am ount/Mo � � s I <br /> 4 ' <br /> a <br /> I hereby certify,t#1af-I have prepared Athis aRplicati6n and that the work will a <br /> be done in accordance wit Joaquin County <br /> .f, ordinances, state laws, a • rules and egul tlo 's Ch he San a n Local Health District. <br /> A'PPLICANT'S SIGNATURE <br /> _ _ 4 <br /> i FOR DEPARTMENT USE ONLY _ r� <br /> Fee Is Due, ❑ ANNUALLY ❑ PER UNIT; ❑ PER SITE ❑ EACH ❑ January Re I By January 31 ❑ July 1 $Received By July 31 k <br /> e <br /> BILLING REMIT <br /> REMITTANCE $ <br /> BASE EXPLANATION DATE DATE EMITTED AMOUNT DUE CHECKED � <br /> AMOUNT <br /> I FEE <br /> I <br /> LESS <br /> - PRORATION i 9 <br /> !!! PLUS <br /> PENALTY - <br /> d <br /> R OTHER <br /> OTHER <br /> FYceilfpby Dat0c Receipt No.; .Perrnit'No.-r Issuance Dale Mailed Delivered <br /> - AP (CANT—RETURN ALL COPIES T0: ENIVIRONMENTAL HEALTH PERMIT/SERVICES - "1601 E.HAZELTON AVE.,P.O-Sox 2009 STOCKTON,CA 955201 <br />