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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ":: i"' <br /> APPLICATION i <br /> _ (For Non-Transferable, Revocable, and Suspendable) !I_ <br /> _ ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> ji <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> N Business Name {SBA) `D.q .PAIGRIS/� �So.r/S Address Po A.-,r 1 4, ,7 .57 W <br /> a Owner I�1 ,Q, /p•A.�..eLS�/ Address j <br /> J Firm Partners, Addresses and Telephone Numbers �} <br /> BGG -- G a Emergency Telephone No. <br /> CL <br /> Business Telephone No. 'L g y p If <br /> Contractor Licence No. sr ;It 3 T---a <br /> L Applicants Name (Print) Fe.O YD ! 10 b 0 D Title 44-sT/,lA720A.___ Date lef Z.- 79 <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 ds <br /> Description(Make/Yr., Color) = �' <br /> Serial No. _CAL._Llcense No. ___— CAL. Lica se Renewal No. <br /> p` y g - _- - - - -- <br /> Capacity Gal., Weights & Measures No. II <br /> Equipment Parking Address- <br /> 2. ❑ PUMPER YARD _ Ir <br /> For July 1, June 30, 19r I I <br /> No. of Vehicles Stored I I <br /> No. of Chemical Toilets Stored I� <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. ! <br /> Test Location Test Date/Time 11 <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location !gS PL-.'t <br /> Owner VI C.-W&JA 1 5777_ Address /graO�I+ <br /> - - d <br /> ,yE <br /> = I? <br /> 10l SEPTIC TANK ❑ CESSPOOL 14 LEACHING FIELD .SEEPAGE PIT ❑ PACKAGE PLANT <br /> E] PERMANENT ❑ TEMPORARY 11NEW REPAIR +_ OTHER Q E 111 SE P1..O7- PGA.V <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 _' <br /> Type Construction = Disposal Site <br /> No. of Units 'Equipment Storage/Cleaning Locations) !t <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location it <br /> Plant Capacity No. Units Serv.ed.- <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19— <br /> SIZE: <br /> 9 SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq.'Ft, <br /> i3 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r <br /> €.f 14 <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 the San Joaquin Local Healfh District. . s kl <br /> Ai <br /> �1 <br /> APPLICANT'S SIGNATURE X <br /> `I <br /> FOR DEPARTMENT USE ONLY <br /> 's _ <br /> Fee Is Due: El ANNUALLY 11 PER UNIT 1:1 PER SITE El EACH. �❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT UUE CHECKED <br /> w— DATI= DATE, REMITTED AMOUNT <br /> FEE Ijr <br /> LESS <br /> PRORATION <br /> PLUS <br /> - <br /> '� PENALTY •...�-=�" - f.14. __ _ a -- -+ �_ � <br /> OTHER <br /> OTHER I} <br /> ! 3 <br /> Received 4y Date Receipt No. Permit No. Issuance Date Mailed Delivered ; <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AYE:,P.O:Box 2009 STOCKTON,.CA_95201 '{ <br />