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Applicatlos W}'ll Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. - <br /> s t '/ � APPLICATION n �3 <br /> 4 n (For Non-Transferable;Retrocable,and Suspendable) SEPTAGE r <br /> ENVIRONMENTAL HEALTH PERMIT Y # e X01 _ SF <br /> ! <br /> di 10 WASTE <br /> Application is ereby made to carry vn business in the jurisdictional area of the San Joaquin.Local.Health District. t <br /> to Business Name (DBA) � ��� ,,,.- Address� k 1t`ti'Sd �ST '.l�- C3 5 2A <br /> z Owner Address ' <br /> JFirm Partners, Addresses and-Telephone Numbers <br /> r a Business Telephone No. ��� Emergency Telephone No: <br /> � Contractor Licence No. Z:S <br /> Applicants Name (Print) LL" Title �� ��i. Dale ""? - <br /> Please check Applicable Category (1-7)and Fill in the Required Information - <br /> 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) v <br /> I For•July 1, � June 30, 19 - Disposal Sites - , <br /> Description(Make/Yr.,Color) ' <br /> Serial No. ( _CA_L.'License No:7 -—*- * CAL:License Renewal No it <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address i <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 V t` <br /> F1 <br /> No. of Vehicles Stored <br /> I No. of Chemical Toilets Stored #' s <br /> 3. ❑ PERCOLATION TEST {d <br /> R.S. or R.C.E. Name + R.S. or R.C.E. No. <br /> Test L cation i ;'Test Date/Time 3 <br /> I 4. SANITATION PERMIT ] +{ #t x <br /> Job Address/Location zq,s'I 5*1_C) L—t i - <br /> O ner (G� x� F Addresses + <br /> SEPTIC TANK ❑ CESSPOOL XLEACHING FIELD SEEPAGE PIT O� PACKAGE PLANT;s'�r <br /> PERMANENT ❑ TEMPORARY I XNEW 0'REPAIR i© OTHER } "fl <br /> S. ❑ CHEMICAL TOILETS For July 1,'_June 30, 19 ) ); <br /> Type Construction Disposal SiteL 1 <br /> No. of Units Equipment Storage/Cleaning Location(s) = f <br /> B. 11 PACKAGE TREATMENT PLANT For July 1, -June 30,19 <br /> Operator Name `'¢ ':'' Where Certified t ' i <br /> Plant Location <br /> Plant Capacity �- 6 No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 ;.-•.�.- � V* -�. «�� '• t.•' > <br /> SIZE: 0 Less Than 1,000 Sq. Ft., 0 More Than 1,000 Sq. Ft. <br /> �.. t <br /> DRY CLEANING, Chals emicUsed/Amount/Mo. <br /> omeowri rcensadagent'sMgnaaturersrti�e fo'lo1N1ng- t reY1<<at`Ethe p arCe'If!he% orkfo wl,ichthis permit isissul;d,lshall not employ any person <br /> in such marmer d5 t0 becorner sab;ect io Po ri-"�;€i'S-�'il�i n-4m." -of F�tf ir; � t � �� � ,� .. , � - <br /> CpnlrACf4r,9 lYlrllf$ or s"i1-r;C�t`PC6r`,0 1"�T- Tt ;." 1 - -1 p. . <br /> 1" Ia+VIr: 'f cert.>y fhb;i.:l tl perforn:aree.�l the t ark for whfcll fhis per lilt is issued,I shall <br /> emp!3y pelscns suli)eft 1lF WOi i.li dl1 b G�nit?f,na iiG:i,o'.'�Gf t.ul,:�+;111,1." + a. r ro <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, a ies and regulati is of the San Joaquin Lo I Health strict.. <br /> t <br /> € APPLICANT'S SIGNATURE X <br /> 1 FFOR.DEPARTMENT.USE ONLY,..-.� //J'an;uary <br /> FeeIs Due: 13ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACHIJanuary 1 &Received B 31 C1July 1 B Received By July 31 <br /> t REMIT <br /> BASE EXPLANATION } 'BILLING REMITTANCE <br /> DATE RATE' AA; k 4TTED - AMOUNT DUE CHECKED <br /> s" AMOUNT <br /> FEE. <br /> LESS ir <br /> PRORATION <br /> PLUS ! <br /> PENALTY - - - - - -- -- - - - <br /> .OTHER I ` <br /> OTHER � <br /> x <br /> ~Received by Date Receipt No. Permit No. - Issu nce Dat Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES Ti ENVIRONMENTAL HEALTH PERMIT/SERVICES "' 1601 E.HAZELTON'AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />