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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 /> t 7 J ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> f rn Business Name(DBA)rLAYQ .,E7. L oyb Address 1AJ 6• /l9.4P�.5" .ST .57�uc ,✓ __ <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> CIL <br /> Business Telephone No. 446'-C-2177Z _ Emergency Telephone No. <br /> Contractor Licence No. G <br /> Applicants Name (Print) &J!�p .<Lfleil7 Title _94% . Date 9 -.02— <br /> Please <br /> LPlease 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(Mak"e/Yr Color)— Y <br /> Serial No. r - ilCAL. License No. CAL. License Rel No. (! <br /> 4 Capacity - Gal., Weights & Measures No, V <br /> pment Parking Address <br /> Equi,2. 0 PUMPER YARD W <br /> Far July 1, - '- June 30, 19 `x" �•:� <br /> ' } 4w1 f rtiwtR <br /> No. of Vehic=les Stored <br /> N f ChemidaIjToilets Stored�`"4. <br /> 3. Gh PERCOL`AiTIONI T6T rap ► ` + =� r <br /> R-S or R.C.E. Name ; .. �� R.S. or R.C.E. No. <br /> Tes fN cation f Test Date/Time <br /> 4. SANITATION PERMIT v'Z9�9 <br /> Job Address/L anon 6,L Il El E <br /> `. O er 0: e' '�"„"�""(' 1 Address <br /> i SEPTIC TArNK '�❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMA NT ❑ TEMPORARY E1 ,NEW ❑ REPAIR ❑ OTHER <br /> S� ❑JCHEIl TOILETS For July Jun '9 <br /> 19 <br /> jType Construction F" Disposal Site <br /> N�o.�UUnits t Equipment Storage/Cleaning Loeation(s)- ^"? � <br /> 16. El-^PACKAGE TREATMENT L-ANT ForAW 1, -June 30',19 <br /> to' — d <br /> ,Operator�Name f- Where Certifi-�-- <br /> .Plant.Location <br /> FPlanti'Capacity rzt, No. Units Served <br /> 7. ❑ LAUNDRY For Julys -June 30, 19 <br /> SIZE! ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,'Chemicals Uaed/Amount/Mo. <br /> S <br /> r <br /> Ll'ffe-7615y ertify that 11 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws; and ru_fes and regulations San Joaquin Local Health District. <br /> I APPLICANT'S SIGNATURE X F <br /> FOR DEPARTMENT USE ONLY <br /> :;Fee Is Due, ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & eived By January 31 ❑ July 1 &Received By July 31 <br /> i <br /> :R }BASE <br /> EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE � 4 /�D <br /> _ LESS <br /> PRORATION~ – <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ed by Date_ Receipt No. a Issuance Date ,Mail Delivered <br /> - <br /> L� APPLICANT—RETLIRN ALL-COMES TO: ENVIRONMENTAL HEALTH ER I ER E 1661 E.HAZELTON AVE.,.P.O.Box 2009 STOCKTON,CA 95201 <br />