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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> Y APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl ication is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) Crutchfield Const. Co. , Inc. Address 332 N. Patrick Road <br /> z Owner Address <br /> J Firm Partners, Addresses andTelephone Numbers 332 North Patrick Road Stockton Ca . 463-5352 <br /> aBusiness Telephone No. 20463-5352 -2 Emergency Telephone No. same <br /> Contractor Licence No. 9 ' - w <br /> Applicants Name (Print) Harold Crutchfield Title 'treasurer Date 4/04/82 <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) C� <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. r . 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 N <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. _ <br /> Test Location _ Test Date/Time + <br /> 4. FX1 SANITATION PERMIT <br /> Job Address/Location 3128 San uinetti Lane Stockton California <br /> Owner Laura Sterner Address-312b Sanquinetti Lane Stockton Calif. <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD -11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> 13 PERMANENT ❑ TEMPORARY ❑ NEW 91 REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -.June 30, 19 i <br /> Operator Name t 1 o Where Certified <br /> Plant Location >. <br /> Plant Capacity No:;Units Served i <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. i <br /> i.y <br /> I <br /> Install (1 ) 481tx 251 Seepage Pit with connection as needed. ! <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 Health District. <br /> APPLICANT'S SIGNATURE X <br /> FORDEPARTMENTUSE ONLY <br /> Fee Is Due: ❑ ANNUALLY_ ❑ PER UNIT* ❑ PER SITE ❑ LACH, ❑ 4nuary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ' - + REMIT <br /> i 5 BILLING REMITTANCE $ <br /> BASE •'' EXPLANATION r- r -r,'_AMOUNT DIE CHECKED <br /> { DATE ,BATE REMITTED a AMOUNT <br /> FEE <br /> 't <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> ! r <br /> OTHER <br /> OTHER 21 <br /> �I t.Y fW ,V�' r;/ `•^ 1/n�-�v:, . <br /> In <br /> Received-by a Receipt No Permit No.i !Esughch Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SgRVLCE! '1601 E.HA2ELT0N AVE.,P.O:Bo.2044'"r'STOCKTON,CA 95201 <br />