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Applications Will 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 <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> H Business Name (DBA) FLO,Y13 .E. LL1fJdF� T Address,� E <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. 44.5-- Z <br /> „3 ,� _ Emergency Telephone No. <br /> Contractor Licence No. 7� <br /> Applicants Name (Print) A5"f,0 W610--D Title 045Wr�.' Date 1r—/2_-9Z <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 <br /> Description(Make/Yr., Color) r <br /> Serial No. _ CAL. License No. CAL. License Renewal No. r <br /> Capacity_ Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1,_ June 30, 19 <br /> No. of Vehicles Stored <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 <br /> 4. kf SANITATION PERMIT <br /> Job Address/Location 4, <br /> Owner 7je .PEzT4/ Address JISIM /2,f7,�E ,lel f9L <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE.PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal SitefV <br /> t� <br /> No. of Units Equipment Storage/Cleaning Location(s) 7 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 -� <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30. 19- <br /> SIZE; <br /> 0, 19SIZE; ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> NomPe�vne-r-' r +M <br /> in SL:Gi1 ir.1C!l:i •1 t vt 5.•••'n*��C'c�*2� tti^`^'.'tel^r Tc� tf 'YEft �i��"•','Ya•s;}!f:a.^Ce?p`?`1P.140f'�:`�'. li?i;' t`;'S^rrR!It°;i^r•, r. ..;�,.I.. <br /> Cnntra.tar"s :.i as o: a 1�rt.tle icier n S, nits,e , tt es y r�ticw..tg. 'i cailfy ibat in the periursrar,:o t,i ilia <br /> emPlay perscri$6:,O;i;ct is"kUti'laa"I's laws 01 6ii1oi,la." <br /> S <br /> I hereby_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 regulations of the qutn Local Health Dista <br /> _p <br /> APPLICANT'S SIGNATURE X 4== � <br /> FOR DEPARTMENT US ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 B Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE S o a <br /> LESS <br /> PRORATION <br /> PLUS t (:F7 <br /> PENALTY <br /> OTHER f <br /> OTHER <br /> Received by - Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />