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Applications Will Be Processed When Submitted ProperlyCompleted BeSureToSign TneAppucauon. <br /> ., APPLICATION <br /> k (For Non-Transferable, Revocable,and Suspendable) SEPTAGE ve�i <br /> ENVIR-ONMENTAL'HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> In Business Name (DBA) ,5 �iGA'C>v/.l Address P-A,"11!f FAIT- r 5T �KPA94; cA. <br /> dOwner N� t G I�^�.,�1 L_L _ Address l� a� <br /> Firm Partners, Addresses and Telephone NumberspALY� T- +p er - �`+7W���� �� J Cel� ��'�"Z <br /> IL <br /> Business Telephone No. -` Z Emergency Telephone No. .SA1-ice <br />� ContractorLicenceNo,�8satf41 - 45&MUD� E, ta`+"f�tit 277 `aT"�-l�S-1 r� 0 G a t. <br /> Applicants Name {Print}�a �L- Title G'►.1't' `CT� Date A 7� <br /> Please check Appl'ic ble Category (1-7)and Fill in the Required Information + <br /> 1. ❑.PUMPER_VEHICLE-PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,�2 a June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. ` <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD ` <br /> For July 1, June 30, <br /> No. of Vehicles Stored _ <br /> No. of Chemical Toilets Stored �r <br /> 3. ❑ PERCOLATION TEST ` <br /> R.S.or R.C.E. Name I I R.S. or R.C.E. No. <br /> / s Test Date/Time <br /> Test Location -0- - <br /> 4. )K S:ANITATION PERMIT <br /> Job Address/Location <br /> ,Owner� a L� IL {y Address k <br /> *� SEPTIC TANK"'-_:.❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT iy <br /> PERMANENT z❑ TEMPORARY _ NEW ❑ REPAIR OTHER .2. - y(ld' tC lZ <br /> 5: ❑ CHEMICAL TOILETS For J.uly,'1,_'_'June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units ~- ,Equipment_Storage/Cleariing'Location(s)_ <br /> 6. 13 PACKAGE TREATMENT PLANT ,For July 1, .June 30, 19 4� <br /> - * Where Certified �$' - ' <br /> Operator Name <br /> Plant Location - <br /> Plant Capacity "�"t 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. <br /> ❑ DRY CLEANING, Chemicals Used/Amourit%Mo. <br /> : ;; <br /> 15 <br /> -. �r <br /> I hereby certify that I have p ar d this_application and that-the_work_will be acc nc hr�San J in nt <br /> ordinances, state laws;`and nd 'lation ' he San oa uin-L•ocal Health <br /> APPLICANT'S SIGNATURE X <br /> 11C3i�La'C©, CALIF. 95351 <br /> C0I3T. LIC. #388144 (209) 577-8522 f <br /> { <br /> FOR DEPARTMENT USE ONLY T <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ® PER SITE ❑ EACH:- ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 35 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> :FEE J <br /> LESS S <br /> PRORATION d <br /> PLUS i I t4 <br /> PENALTY <br /> 1! <br /> OTHER e <br /> OTHER J } <br /> Received by Date Receipt No. -. Permit No. Issuance Date Mailed Deliv red <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O-Box 2009 STOCKTO ,CA 952 1 - <br /> - -- <br /> Mat <br /> t <br />