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Applications Will Be Processed When Submitted Properly Compiemo. <br /> APPLICATION SEPTAGE <br /> (Far Non- MENTAL HEALTH PERMIT able, Revocable,and le) <br /> ENVIRONMENTAL <br /> LIQUID WASTE <br /> Edwards Sons Address 6352 West Canal Blvd. <br /> Appficatiort is hereby made tocarryon business in the jurisdictional area of the San Joaquin Local Health District <br /> Wllllam D . 6352 West Canal Blvd. <br /> N Business Name (DBA) & Address <br /> Edwards <br /> aowner <br /> Firm Partners, Addresses a8n35e1ep651 Numbers Emergency Telephone No. f <br /> $ Business Telephone No. 4 Date Au 4 98 <br /> a 31791:5 Title owner � <br /> j Contractor Licence No. Wl lllam D• Edwards <br /> Applicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> I` 1, [1 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE <br /> For July 1, June 30, 19 <br /> Disposal Sites <br /> CAL. License Renewal No. i <br /> Description(Make/Yr., Color) CAL. License No. <br /> Serial No. <br /> Gal.,Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> 2 ❑ PUMPER YARD j <br /> I For July j,_ June 30, 19 �— <br /> j No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.G.E.No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> q, 14 SANITATION PER T <br /> Job Addr s Locat' t,,� ddress Q <br /> 4 Owner ,pj LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> f 14 SEPTIC TANK ❑ CESSPOOL ❑ REPAIR [IOTHER <br /> C ❑ PERMANENT C3TEMPORARY NEW <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Disposal Site <br /> Type Construction Equipment Storage/Cleaning Locations <br /> F No. of Units 1, -June 30, 19 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July Where Certified <br /> Operator Name <br /> k Plant Location No. Units Served <br /> i Plant Capacity <br /> 7, 11 LAUNDRY For July 1, -June 30,�9Mor 1.000 Sq. Ft. <br /> SIZE: 13 Less Than 1,000 Sq. Ft., ` <br /> t ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> i <br /> II be done in accordance with San Joaquin County <br /> I hereby certify that I have prepared this applicatti the <br /> that <br /> Local H alth District. <br /> t ordinances, state laws, an rule and regul <br /> I: <br /> APPLICANT'S SIGNATURE X <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> ` ❑ July 1 &Received By Juiy 31 <br /> ! ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 REMIT <br /> I PER UNIT CHECKED <br /> Fee is ❑ ANNUALLY BILLING REMITTANCE AMOUNT DUE AMOUNT <br /> BASE EXPLANATION DATE <br /> DATE R TED <br /> 1 ' , <br /> I FEE <br /> f <br /> LESS <br /> PRORATION <br /> j PLUS <br /> PENALTY / <br /> i OTHER <br /> F OTHER <br /> a-- S y <br /> ailed Delivered <br /> Permit No. issuance Date <br /> M <br /> + Received ey Date <br /> Receipt No. 1601 E.HAZELTON AVE.,P.O.-Bor 2009 STOCKTON,CA 85201 f <br /> ES TO: -ENVIRONMENTAL HEALTH PEAM4TlSERV10ES <br /> APPLICANT—RETURN ALL COPIt� <br /> - <br />