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Applications Will Be Processed When Submitted Progerly.Completed. Be Sure To SignTheAppucanon. y <br /> APPLICATION _ <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> ocal Health District <br /> Application is hereby made to carry o business in the jurisdictional area of the San Jogpuip l <br /> y 114id State Manufacturing, ITiC Address .. R oll Calif- 95366 <br /> Business Name (DBA) � <br /> 3atme Address ` <br /> z Owner I <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers C <br /> CL <br /> Business Telephone No. e�3C�..L. - Emergency Telephone No. <br /> Contractor Licence No. �' 10 4i�...fa?L S <br /> a LI3^r cs . 'id af�,an Title cQ� - Date <br /> L Applicants Name (Print) <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) CAL.License Renewal No. <br /> CAL. License,No+Se,rial No <br /> Gapacity r --;Gal., Weights y&'Measures No.tr y <br /> Equi ment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 R <br /> No. of Vehicles Stored ��� �f bac: <br /> 1 _ - _ <br /> Na. of Chemical Toilets Stored '-T, +-+ <br /> 3. ❑ PERCOLATION-TEST <br /> t ! R.S. or R.C.E.-No.:,;_ ' <br /> R.S. or R.C.E. Name <br /> Test Location f Test Date/Time f - i <br /> 4: 13 SANITATION PER141T� � on, Ca .. i� on siad l6r off liill� �_�� <br /> Job Address/Locatign _ y+ i SC'LCITI on, Ca � <br /> M. • k. {t •t f (Address <br /> Owner b.^��x9.'I�1_� a�'�: r • ,u J <br /> `" 13 LEACHING PIELD '0.''SEEPAGE PIT i PACKAGE PLANT ; <br /> 23 SEPTIC TANK ❑ CESSPOO_L ❑ REPAIR <br /> 13 NEVV ❑ OT1iER <br /> �' [ I <br /> PERMANENT ❑ TEMPORARY ^ r`t b� <br /> 5. ❑ CHEMICAL•TOILETS For July 1, -June 30, 19 � 4 <br /> Type Construction x' i..�.� r DisposaIPSite t-, _ <br /> I ji t <br /> -Equipment StoragelCleaning Locations) µ <br /> 6., ��PACKAGE-_ TREATMENT PLANT For July 1, -June 30, 19 �.-. -�-. s es;q <br /> Where Certified <br /> Operator Name - <br /> Plant Locat ,� <br /> ion:' - <br /> •`l?iant Capacity t No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -Ju'ne 30,"19-__._r_— T <br /> SIZE: ❑ Less Than 1,000 Sq. Fti, ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Use+/Amount/Mo. <br /> f � <br /> l <br /> I hereby certify that I have prepared this application and,that the wokW111 be done in`accoldance with Sa:Joaq:uinCounty <br /> ordinances, state laws, a11d rules and regulations 6f06 San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE L -A <br /> } f T <br /> r � <br /> rf c-• � <br /> i FOR DEPARTMENT USE ONLY <br /> _1Y .✓ <br /> r <br /> Fee Is Due: C1 ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH ❑ January I &Received By January 31 ` ❑ Jul4 n&Rei e'°REMIT <br /> BILLING <br /> 31 <br /> BILLING REMITTANCE -AMOUNT DUE 1 -j.CHECKED <br /> �p BASE EXPLANATION DATE t DATE REM�IfTTED - AMOUNT <br /> FEE <br /> LESS <br /> PRORATION i <br /> I <br /> PLUS E <br /> PENALTY <br /> !" <br /> OTHER <br /> OTHER <br /> Q-1 ) <br /> Receipt No. Permit No. Issuance Date Maiked Delivered <br /> Received by D to 1641 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 85201 <br /> APLI <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />