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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 /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT I <br /> LIQUID WASTE <br /> Applicatippppppn is here y made to carry on business in the jurisdictional area of the�San Joaquin Local Health District p <br /> rn Business Name (DBA)�lrr/-A i _GAz Address-P a X /y,5'-V .�7!:�fJ Zi—and/ .0 <br /> z Owner Address <br /> C <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL <br /> Business Telephone No. y66' y6d7 Emergency Telephone No. <br /> -J Contractor Licence No. oZ �3U <br /> L Applicants Name (Print) 4-0.V VI£ 64..09/1 ' Title 6 S7_1M,1 7&,r- Date 1-�2-'� 79' <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. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets 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 /> 4. W SANITATION PERMIT <br /> Job Address/Location n <br /> Owner J-/,JO �3,�Frr7 Address/ ,� ��7rZ RSL 7r�f' ti <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW :9 REPAIR ® OTHER /S1 Y3o 7 FLTt,- 13 4 Q <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 Q� <br /> Type Construction Disposal Site t'J <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified _ <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X C�!� - <br /> Z :7 <br /> all <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE �" S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY t! Z ` <br /> OTHER <br /> t <br /> OTHER 1 <br /> -7 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />