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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) SEPTAGE <br /> 411 ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTET <br /> Application is hereby made to carry on business in the jurisdictional area of the San.Joaquin Local Health District <br /> y Business Name(DBA) � �JC.?C: . Address��3- sem � K �SZC� <br /> z Owner Address <br /> Q Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No.--_442�G—�0-7 _ Emergency Telephone No. <br /> Contractor Licence No. . ZS" <br /> ` 4 <br /> yApplicants Name (Pringl�t.- � _ TitleDate <br /> wT Please check Applicable Category(1'-7)and Fill in the Required Information ice; ye: It',J -,, _j <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. <br /> Gal.,Weights & Measures NO. k, <br /> Equipment Parking+Ad66F s - <br /> 2. 11PUMPER YARD',-.,.., f <br /> For July 1, June 30, 19 ` <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored ` <br /> 3. ❑ PERCOLATION TEST; r <br /> R.S. or A.C.E:Name 'r ' T"� R.S: or R C.E. No. ) <br /> Test LO ation Test Date/Time t [ 1 ) <br /> 4.F L�-SANITATION PER1411Tf " <br /> Job Address/Location 0 _._ L_1• �. tir'� y <br /> OwneryAdiiFesS w` # <br /> SEPTIC TANK = D CESSPOOLS�',�LEACHING FIELD' D°SEEPAGE PIT 1 ❑ PFjCKAGE PLANT �- <br /> MIPERMANENT [!"TEMPORARY-- -0—NEWw 1 p"REPAIR,` ; OTHER i s <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site A <br /> No. of Units Equipment Stora6e/,Cleaning,09cation(s) <br /> 4 , •. � -s ..4gyMWt; f � <br /> '�6: 0 PACKAGE_TREATMENT>PLANTi'For,July'l1 _'"June 30, 19 r <br /> Qperator'Narrle _A '- "- ---- i - — Where Certified`"- <br /> Plant Location •w t �' <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. r, <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 4 <br /> I hereby certify that I ha prepared thi's application and that the work will be)done in accordance with San Joaquin:County <br /> ordinances, state IawS, nd ules and re lations o he San J uin ocal Health.District. <br /> APPLICANT'S SIGNATURE X , ' <br /> ��- FOR DEPARTMENT USE ONLY'-,�` ! I <br /> i , �a ( t <br /> _Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1"&Received By January 31 ❑ July 1 &Received-By July 31 <br /> BILLING REMITTANCE $ s REMIT <br /> BASE EXPLANATION AMOUNT DUE � CHECKED - <br /> DATE DATE - REMITTED AMOUNT -' <br /> FEE <br /> LESS <br /> PRORATION ^- - <br /> PLUS t1 I <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by + Date Receipt No: ermit No.'- y I suan D te- - ' 'Mailed De red d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES'' 1801 E.HAZELTON AVE.,P.O.Bok 2009' STOCKTON,CA 95201 1J <br />