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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> " APPLICATION <br /> 0-0 <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> Y / ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE , <br /> Applicab a{ y�n o �j bu s In the jurisdictional area of the San Joaquin Local Health District <br /> I` y Business Name (DBA) ? > �� ""��I- Address P.O. BOX 1090 Tracy, Calif. 95376 <br /> i Owner d Sanders;R. Brown, ar aha AddressCalif. 937_6 <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers q <br /> CL <br /> Business Telephone No. 464-83611466-0565 <br /> 0565 Emergency Telephone No.931-0146/946/0354 01 <br /> Contractor Licence No. 272220 Class <br /> LApplicants Name (Print) 11-T, Sanders Title SU ertindent Date October 24 19$ <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) <br /> Serial No. CAL. License No. CAL. Lic:nse Renewal No. <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.G.E. Name R.S. or R.G.E. No. ' <br /> Test Location Test Date/Time <br /> 4. )(MXSANITATION PERMIT <br /> Job Address/LocationCalif- <br /> Owner <br /> M <br /> Owner. Marl ey Cool i ng Tower Co. Address 150 N. Sinclair St. Stockton, Ca. <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW M REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site Zz <br /> No. of Units Equipment Storage/Cleaning Location(s) <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: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. 1 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify tha hve pre red thi application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state I s, nd r and reg ations of the SOJoaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> {{ DATE DATE REMITTED AMOUNT <br /> — <br /> FEE r.. <br /> LESS f r <br /> PRORATION } <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> /6 <br /> Received by ate Receipt No. Permit No, Issuance Date Mailed Delivered <br /> �APPLiCANT—RETURN ALL COPIES TO: ENVIRONMENTAL NEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ST,OCKTON,CA 95201 <br />