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y Applications W I Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.
<br /> APPLICATION
<br /> (For Non-Transferable;Revocable,and Suspendable) ] SEPTAGE
<br /> ENVIRONMENTAL HEALTH-PERMIT I
<br /> LIQUId WASTE
<br /> Application is/hereb made to carry on business in the jurisdictional area of the San Joaquin Local Health District
<br /> y Business Name (DBA) / f /L-6 .C`2 _-.Address
<br /> I a Owner— - l .. �. �� LG e; or- -Address _
<br /> Firm Partners, Addresses and Telephone Numbers
<br /> aBusiness Telephone No. �- Emergency Telephone No.-. -
<br /> Contractor Licence No. E
<br />!,4Applicants Name (Print) f Title T� �aEL.� Date
<br /> r Please check Applicable Category(1-7) and Fill intheRequired Iriformation
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> For July 1, June 30, 19 ';-Disposal Sites - -
<br /> Description(Make/W., Color)
<br />' Serial No. CAL. License No. CAL. License Renewal No.
<br /> rCapacity. _ -•Gal:, W eights-&-Measures-No.=-- 4 --- - ---- - -----
<br /> Equipment Parking Address
<br /> 2. ❑ PUMPER YARD
<br /> For July 1, June 30, 19 r No. of Vehicles Stored t
<br /> No. of Chemical Toilets Stored
<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 r�
<br /> 4: ❑ SANITATION PERMIT e f=
<br /> Job Address/Location
<br /> Owner - r Address Q�2 ZWX
<br /> M-16TIC TANK ❑'CESSPOOL= LEACHING FIELD © SEEPAGE PIT ❑ PACKAGE PLANT
<br /> ❑ PERMANENT' ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER
<br /> �.
<br /> S. 1:1 CHEMICAL TOILETS For July 1,-June 30, 19
<br /> Type Construction �_ Disposal Site - -No. of Units "` Equipment Storage/Cleaning Location(s)
<br /> �f_; _-
<br /> fi. 11 PACKAGE TREATMENT.PLANTS For July 1, -June 30, 19
<br /> .Operator Name Where Certified
<br /> ;Plant Location
<br /> L .
<br /> Plant Capacity ( I t No. Units Served ` '
<br /> 7. ❑ LAUNDRY For Juiy f, -June 301 19 ! -
<br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Fes--# t
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/MO.
<br /> .>, ,,, 4Y1y.f.al. a-x.�h •" w -msµ �F 4-.I. _ .. �
<br /> hereb'y'certify that'l have prepared this application and that the work will be:done in, accordance with San Joaquin County_ '
<br /> . ordinances,state laws, and rules and regu`f ;ions of the Sag,,Joaquin Local Health District.
<br /> I .. �. .%
<br /> APPLICANT'S SIGNATURE X -
<br /> f0_R DEPARTMENT,USE ONLY•
<br /> �, F fL-
<br /> 1 r1
<br /> f fee Is Due: ❑ ANNUALLY ❑ PERINIT' ❑ PER SITE "❑ EAti` ❑ January 1 &Received By January 31 ❑ July 1 &Received By July31
<br /> _ REMIT
<br /> BILLING REMITTANCE + $-. '
<br /> BASE EXPL-ANATION------=..-- - _y-2-•---.Y --r-- -- J AMOUNT DUE CHECKED
<br /> G. - - !- DATE DATE'; } REMITTED- - AMOUNT 'I
<br /> FEE t ..a _ cy
<br /> LESS
<br /> PRORATION 6' - '14
<br /> PLUS
<br /> PENALTY
<br /> 1..
<br /> ...-ETHER ..'�-T.."^`""' -.w':-""'.., .-......-.--C--'"-" ..,�a+>--,.--, "^'"'r-,.- �_'�"'^'.�- -..:+w..�+,�-,-J..-�..w-,.•.y --�,.�-•.�*--" +-..,.,-....-,�-�«�
<br /> �' ..r,t,.,OT,HERS.'-� -+`+v-'�».e-.�,-,�...^ .. .t--,�.w:-��-.-•.x...K..�„x_,s- �«. „�-... � .: _ - '-«...'rv-.,--:....+�-
<br /> i Received by .Date j( Receipt No. Permit No ssua ce Date Mailed Delivered
<br /> APPLICANT—RETURN ALLCOPIESTO: ]ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 "STOCKTON,CA 95201
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