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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 /> Appl Icati s hereby e to carte on business in the jurisdictional area of the San Joaquin Local Health District <br /> N Business Name (DBA) C! — ;11�7_ �5 OIC 457 Address 1,210,57 S-, <br /> cOwner r E/C IC& Address -57, L � <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 4zz —02G/4 Emergency Telephone No. <br /> Contractor Licence No. 2 <br /> �ApplicanYs Name (Print)" Title X577 Date 2B 747 7,? <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 0 19 _ Disposal Sites <br /> Description(Make/Yr., Color) __.. <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. t� <br /> Equipment Parking Address _ # <br /> 2. ❑ PUMPER YARD �..,......�......�...,�.�.. �... �.-...� -�.- - - <br /> For July 1, June 30, 19 • <br /> No. of Vehjcles Stored �• w� - <br /> No. of Chemical Toilets Stored - + <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.G.E. Name I R.S. or R.C.E. No. <br /> Test Location I Test Date/Time ( <br /> 4. WSANITATION PERMIT Al. <br /> Job Addres ocation I �"_X � ���� �7C <br /> Owner — A'77 � �� _ Address 40 ;Z-1 ;J <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELDtA❑:SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW .� REPAIR OTHER 5EeM,0 <br /> 5. 1:1 CHEMICAL TOILETS For July 1, -June 30;#1L v <br /> I <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) _ <br /> 6. 11 PACKAGE TREATMENT PLANFor July 1June_3_0,,19 1h1Z,�\� I r <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: ❑ Less Than 1,000 Sq. Ff., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. r,_ � ���► <br /> I hereby certify that1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a r and regulatio s of the an Joaquin Local Health District. <br /> a <br /> APPLICANT'S SIGNATURE _._._. <br /> !0 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due; ❑ ANNUALLY�;� '❑ PER UNITS ❑ PER SITE ❑ EACH ❑:Jen'Uv`1'&Received By January 31 ❑ Ju$y 1 &Received By July 31 <br /> REMIT <br /> I BILLING REMITTANCE $ II <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> II DATE DATE REMITTED I AMOUNT <br />- FEE y!A .!p <br /> LESS I <br /> PRORATION <br /> PLUS i 1641 A <br /> PENALTY a V <br /> ck <br /> OTHER <br /> OTHER ! <br /> (� <br /> i --�It1 <br /> Received by - Date Receipt No. Permit No. Issuance Date Mailed eliv d <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />