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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transierable,"Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT �. <br /> LIQUID WASTE <br /> t Application is hereby made to cirry on business in the jurisdictional area of the San Joaquin Local Health District <br /> H Business Name (DBA) 7 ,-r Address /g o, / �2 1 S!rb -l•y Z©r- <br /> aOwner Address v <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No, Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> L Applicants Name (Print) —Title S Date 'Y-2,1–B 7__ <br /> c�C� <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 l <br /> Description(Make/Yr., Color) f <br />` Serial No. CAL. License No. CAL. License Renewal No. !7 <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> k For July 1, June 30, 19 <br /> I No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST i <br /> R.S..or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. j& SANITATION PERMIT <br /> Job Address/location ' jl2y _A - �� <br /> Owner (; Address e <br /> Df SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> IE PERMANENT ❑ TEMPORARY Z NEW CD REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 # " <br /> Type Construction . Disposal Site <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 /> II Plant Location I <br /> I Plant Capacity L '- No. Units Served <br /> t 7. ❑ LAUNDRY ` For July 1, -June 30,:1.9 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,` ❑ More Than 1,000 Sq. Ft. <br /> © DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 43ti� gMfyVr �D,rZ ESIi 3s�4$�{•JlUf�p�1AJ�S p s FG payvSAf �J a ! #"f5339lpC±o{ s!v1o#klplalIiGifhi j9erml�.i3i$ativ'A,l.�flatin9tEm !� a r <br /> "r �r �b.cxtrelcx;na �� P Y n3 person <br /> �mp9ey F.,r;p § ,gCI vrc k^Ian's c9t�lperi at o an o.s C,$f, ��4ott9wir��; "3 Comfy iha:Sri the perforn341nro of tilt vitt for t9hicti this permit is issued,t shat! <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 tf q San Joaquin Local Health District. <br /> p 001 <br /> APPLICANT'S SIGNATURE X ' 7 <br /> 0 <br /> . ' FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER'UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receive¢By January 31 ❑ July 1 &.Received By July 31 <br /> _._ REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE �. gA7E /E: REMITTED AMOUNT <br /> FEE <br /> LESS <br /> -PRORATION -- - . <br /> PLUS <br /> PENALTY <br /> " f f <br /> OTHER „I <br /> ` OTHER - <br /> Received by Date Receipt NoPermit No. IsWce e Mailed Delivered . <br /> APPLICANT—RETURN'ALL COPIES TO: `ENVIRONMENTAL HEALTH PERMITISERYICES 1601 E.HAZEL ON AYE.,P.O.Box 2009 STOCKTON,CA 95201 <br />