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MF PII%10tIV11J \f lt/WV VI U{.CD.ICU \r I IC[I QUUl t11IICU PIUFJCI I VUI I1PICICU. OC JUIC I U o1v1I I IIC P%P P1IUat1U11. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application Is he eby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> FBusiness Name (DBA)T)6- �� 1 � �, L. ,.,MQ Address )&VX MSV 3 R5 z,- <br /> .a Owner Address <br /> �.Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. � <br /> L Applicants Name (Print) Title M 14-A-2 A<7 Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE). <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. TM CAL. License Renewal No` ti <br /> Capacity ,� Gal.,Weights&Measures No Y I 4 <br /> Equipment Parking Address <br /> 2. PUMPER YARD <br /> For July 1, June 30, 19 t <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored: <br /> 3. 11 PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E.No. `,.s <br /> Test`Location Test Date/Time <br /> 4. SANITATION PERMIT � ^ <br /> Job Address/Location f' CAK410 <br /> Owner <br /> ❑ SEPTIC TANK ❑ CESS.PO L LEACHING FIELD PIT ❑ PACKAGE PLANT: <br /> Jff_PE MANENT, ❑ T MPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Sits`' <br /> No. of Units Equipment Storage/Cleafllga Location(s) <br /> 6. Q PACKAGE TREATMENT PLANT For July 1, -June 30, 19-1 <br /> Name <br /> Operator ' ' <br /> p r ¢ 'E Where Certified <br /> Plant Location <br /> Plant Capacity Nr-l,lnits Served <br /> 7. ❑ LAUMMY" For'July j,_June A 19r ° " <br /> SIZE: ❑ Less^Than~1,000 Sq. Ft ❑ Alore Than SqF <br /> ❑ DRY CLEANING,Chemicals Used/ .unt/Mo. 't <br /> Home @°.fy a44C1a gnzedp F a s2r er'.,-f e kt,C10!'�t+k q (r.('t:{! r -+.`;?C"``€`. '_' 1T1:ice o ft be vvo I:lerwl"ich this pet m it is issued,I shall' employ any person <br /> in such rr nrt as to bece-m ` `.ci�7 <br /> OslsYracter' �hlrer�� �1' ';f `}t-1 � , �ctn� ua scrRfiea.�l�s; °�i av,en�. `'Cc t �, .„`in the�erior:tla[;iie of tli8 tvCrl?�ft1r whie;s�ihispew€�14 is-issued l shed.! <br /> employ pl rs suntaet to air n1�-f c� 1pansualo,i-V&tlf California.' � <br /> :. <br /> F hereby-ee-W that I hay4 prepared this application and that the work will be done in accordance with San Joaquin Ceountykjt. <br /> ordi:nbtnces;Z&e laws, and re it.Mionp.Af 4 . . ap Jo n Lo I Health District. f :A <br /> APPLICAN T SGATURE X � <br /> .: <br /> # FOR DEPARTMENT USE ON - <br /> Fee"irs Due: ANNUALLY PER UNIT ❑ PER SITE ❑ EACH 11 Jan r Received By January 31 ❑ July 1 &Received By Juty 31.F <br /> BILLING.—- .. WN $ REMI �`TBASE EXPLANATIONAMOUNT DUE CHECKi <br /> DATE REMITTED AMOUNT <br /> FEE ; <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> s <br /> OTHER t p <br /> .. ..5 wx:.:. <br /> Received:by Date Receipt No. Permit No. Jsssah ate Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16tli E.'tHAZEL fON AVE.,F.U.Box 2609 STOCKTON,CA 95201 <br />