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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) f 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 r <br /> ,Fton, ra. .913206 <br /> Business Name (DBA) STANFIELD AND MOODY, INC. 'Address -.P.O. ,BOX 6GG5 St <br /> F Sanders,, R. Brown,. & G. Carbajal Address P.O. Box,,6GG5 Stockt-n a <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. 466-6966 Emergency Telephone No. 09-931-0746/�i4r,-og54 <br /> a <br /> � Contractor Licence No. :272220. Class A. <br /> Applicants Name (Print) J.T. Sanders Title SU ert.indent ... Date June.. <br /> Please check Applicable Category (1-7)and Fill in the Required Information r• <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, _June 30,19-- Disposal-Sites - <br /> Description(Make/Yr., Color) l <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> .Equipment Parking Address <br /> 2. E-1 PUMPER YARD <br /> For July 1, June 30, 19 V` <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 /> i 4. -UNSANITATION PERMIT \ <br /> Job Address/Location 150 N. Sinclair Street Stockton Ca. <br /> Owne;'he Marled Coolingr Tower Co. Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ZrREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 301 19 ^ .1 h 2 r T& 3- <br /> Type Construction Disposal Site 1 <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 a <br /> Plant Capacity No. Units Served <br /> I 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. <br /> - ' 1 <br /> I hereby certify that ave pre ared his application and th a work will be done in accordance with-San Joaquin County <br /> ordinances, state la d u1 and re ti ns of the San J n Loca Health District. <br /> I APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY - <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT, ❑ PER SITE ❑ EACH jo January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> t - - - REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> I <br /> LESS <br /> ' PRORATION ' <br /> PLUS 9 <br /> PENALTY <br /> w r ✓ <br /> F OTHER <br /> OTHER - <br /> Received by Date Receipt No. Permit No. Issuance Date k_Ajaiffled_ Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95201 <br />