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