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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) r, ` <br /> SEPTAGE, . . . <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE. , , R - f`. ,= 1 `� �•� <br /> Application is hereby made to carry on business in the jurisdictional area of ttLe San JLoaquin Local H i <br /> FBusiness Name (DBA)D.A. PA1?_)Lu<_J4F mac_Address CL <br /> z Owner ��,Address <br /> ___ <br /> a <br /> .. - <br /> j Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. �-� -- 173 45 <br /> L Applicants Name (Print) Lj �. s - _. Title Dateri— _M <br /> Please check Applicable Category.(i-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30,19 r. ; Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No.a- CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. ! <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD - <br /> For July 1, June <br /> No. of Vehicles Stored i f <br /> No. of Chemical Toilets Stored I } <br /> 3. ❑ PERCOLATION TEST s _ t ir4 (' } <br /> R.S. or R.C.E. Name t R-S.or R.C.E. No. vtl <br /> Test Location 4 r ( Test Date'/Time <br /> 4. <br /> 4. B SANITATION PERMIT I - : _, <br /> Job Address/ cation Z + r <br /> Owner Q <br /> er Address aJ�� ��1� C=4 � 7-0 .� �T" S7 'e l� <br /> I=TSEPTIC TANK ❑ CESSPOOL 4'. LEACHING_ FIELD❑ SEEPAGE PIT ❑-PACKAGE PLANT <br /> O�RMANENT ❑ TEM_PORARY ❑ NEW C�PAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -`June 30, 19 11. f" ^ - "" ■ <br /> Type Construction + 1. <br /> Disposal Site.. " e!- '. t <br /> No. of Units E�uiNment Storage/Cleaning Location(s) ` <br /> 6. ❑ PACKAGE TREATMENT PLANT; ''For,Juiy„J1;11June 30, 19 " <br /> Operator Name Where Certified <br /> Plant Location u '� >�� ty <br /> Plant Capacity r �L" 4 - No°Units Served r Ylt' <br /> 7. ❑ LAUNDRY For July 1, s June�30, 19 a ' <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ,;�❑�M1ll e.Than 1,OOOdSq°.Ft. : # t <br /> DRY CLEANING, Chemicals Used/Aro nt/M0. <br /> I hereby certify that I hav re ared this application and th t the work ill be done in accordance with San Joaquin County <br /> ordinances,state laws, and regale ' s of the S oaquin I HeaF�h District. <br /> 1 +*-.r <br /> APPLICANT'S SIGNATURE X - <br /> FOR DEPARTMENT USE ONLY P <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH r ❑ January i &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING - REMITTANCE <br /> S-r $ <br /> BASE EXPLANATION - AMOUNT DUE CHECKED <br /> DATE p DATE.- R1MITTED - AMOUNT , <br /> FEE a �- <br /> ,4 LESS <br /> R()BATION^.P"[ W. <br /> PEN t ^ <br /> OTHER " r <br /> OTHER -;--° 'N �. �^ �-.-' " ri �.... ''•4 -- <br /> y �. f:3 y� <br /> r Received by Date Receipt No's Permit No._ Issu ce Date Mailed Deliv i <br /> — APPLICANT—RETURN ALL COPIES TO:-. ENVIRONMENTAL HEALTH PERMIT/SERVICES. -� 1601 E.14AZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />