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Y Will-Be Processed. <br /> Submitted Properly comP+G«u• <br /> gppwcattons w' APPLICATION <br /> f,- <br /> (For Non-Transferable, Revocabie,`and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE i <br /> In is hereb made to car o busin ss,+ the jur'sd ctional ddressthe San Joaquin Local Health District <br /> Applicatl� L� A <br /> mBusiness Name (DBA) Address <br /> a Owner <br /> Firm Partners. Addresses an telephone Number Emergency Telephone No., <br /> cJ 0. Business Telephone No: Date <br /> Contractor Licence No. Title <br /> 1 <br /> .Applicants Name (Print) r , ' <br /> v Please check Applicable Category (1-7) and Fill-in the Required Information r.. <br /> �. ❑'"PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) n <br /> Disposal Sites lJ l <br /> For July 1, -June_30, 19 y <br /> Description(Make/Yr.,Color) r CAL-:-License Renewal No. <br /> CAL. License No <br /> I Serial No. _-_1 <br /> Capacity -GaI.,-Weights-e-Measures No- - <br />' Equipment Parking Address <br /> z, ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> > No. of Vehicles Stored <br /> r <br /> No. of Chemical Toilets Stored 3 <br /> 3, ❑ PERCOLATION TEST R.S.or R.C.E. No- i <br /> R.S. or R.C.E. Name Test Date/Time (,,ur I-C mow, <br /> I Test Location <br /> q, El SANITATION PERMIT" w £ <br /> Job Add R3s /Loc,.ion ' <br /> ��� �y Address ❑ PACKAGE PLANT <br /> Owner -Wt-'LEACHING FIELD SEEPAGE <br /> PIT Q <br /> ❑ SEPTIC TANK ❑ CESSPOOLS r /L$IiEPAIR ❑ OTHER <br /> ❑ Pi NEW //-A r I <br /> i x <br /> ' ERMANENT ❑ TEMPORARY , V <br /> ' ` '' g <br /> g. ❑ CHEMICAL TOILETS For'July 1,-June 30, 19 <br /> ,) Disposal Site <br /> Type Construction t C <br /> � No. of Units - ^` Equipment Storage/Cleaning Location(s) <br /> g,�❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> i Operator Name <br /> L Plant Location No: Units Served` <br /> Plant Capacity - EI <br /> -7:-❑ LAUNDRY 'For July 1,-'June 30, 19� E <br /> _ SIZE: ❑ Less Than 1,000 Sq. Ft., El More Than 1,000 Sq. Ft. „' <br /> ❑DRY CLEANING,Chemicals Used/Amount/Mo. <br /> ta tired this.appiicti n and that the rk will be done in accordance with San Joaquin County <br /> I hereby certify that Tlha, exp �.1 <br /> _ ordinances, tate-1a s, a d rules regulat-iOne Sa Joaquioeal H th�District. <br /> C` <br /> APP'LICANT'S SIGNATURE X 4 —' <br /> F i <br /> C CII. <br /> 5 Y `� <br /> FOR DEPARTMENT USE ONLY <br /> PER SITE ❑ <br /> EACH January 1 &Received BySanuary 31 ❑ July 1 &ReceiveRdEBhlTuly 31 <br /> Fee Is Due: ❑ ANNUALLY PER UNIT` REMITTANCE $ AMOUNT DUE CHECKED I <br /> 'BILLING REMITTED- AMOUNT <br /> BASE EXPLANATION :-DATE �' DATE <br /> FEE - �i (L�V � � ��� _. . � � _ �h US•.L� t <br /> LESS _,. e ^"-• fyli iry *47- -4v-prp' r'i�-� yJ PJ <br /> .'PRORATIOI`J'-�"-'�'"" <br /> PLUSf k ✓rte C A <br /> PENALTY G h <br /> OTHER LV <br /> OTHER <br /> BIssuance Dat Mailed Delivered c� <br /> Receip . - Permit No. STOCKTON,CA 95201 <br /> Received by ate t No1801 E.HAZELTO A.tI Box 2009 <br /> APPLICANT-RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />