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Applications Will Be Processed When Submitted Properly Completed. Be SureToSign IneAppncanvn. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> .0 ENVIRONMENTAL HEALTH PERMIT r <br /> [. LIQUID WASTE <br /> Application is reby made to carry on business in the juris ictionai area of the San Joaquin Local Health Distr' t <br /> .Business Name (D A) ' �""- Address- -76 7h <br /> Address <br /> a Owner 11 <br /> : Firm Partners, Addresses and Telephone Numbers I <br /> a - -1-1 0 �4~ Emergency Telephone No. <br /> a Business Telephone No. — <br /> 1 Contractor Licence Na. `;? ` Z 2- <br /> a Ff Cfa_ef-iC rz Title �'1`"_S Date 'Z�� �/ <br /> L Applicants Name (Print) <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 30,79 Disposal Sites <br /> Description(Make/Yr., Color, <br /> Serial No- CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures Na. <br /> Equipment Parking'Address <br /> 2.�Q.'PUMPER YARD <br /> For July 1 June 30, 19 t ' <br /> No. of Vehicles Stored " I <br /> No. of Chemical Toilets Stored # <br /> 3. ❑ PERCOLATION TEST <br /> l R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> k Test�Lo tion Test Date/Time <br /> 4. L SANITATION PERMIT <br /> F Job Address/LD Address ion r' -x`lolqq JCO) <br /> t Owner <br /> ,LLQ 0-k --2 a [3s�.+ � ♦' v-r;@r <br /> T SEPTIC TANK' ❑ CESSPOOL LEACHING FIELD 11 SEEPAGE PIT 11 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW L+1 REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> i 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 /> Where Certified <br /> Operator Name I <br /> I Plant Location ) <br /> Pians Capacity <br /> I No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19- L__� <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft.. <br /> r ❑ DRY CLEANING, Chemicals Used/AmounVMo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance wiSan Joaquin County <br /> ordinances, state laws, and rules a regulations of the Joaquin Local Health District. <br /> APPLICANT'S SIGNATUREX � <br /> t <br /> FOR DEPARTMENT USE ONtY`'r R <br /> ` Fee.ls.Due: ❑+ANNUALLY ❑ PER UNIT El PER SITE C1 EAC ;❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> l REMIT <br /> BASE EXPLANATION BILLING R£MITTANGE�.. ��....� ..�.+ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE # <br /> LESS <br /> PRORATION <br /> PLUS ► es� <br /> PENALTY <br /> OTHER ! <br /> OTHER <br /> C �'Received by Date Receipt No. Permo. Issua cc Date M 'led Delivered <br /> -- <br /> 1601 E.HA2ELTON AYE.,P. .Box 2009 STOCKTON,CA 95241 <br /> APPLICANT_RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />