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Applications lWill Be Processed When Submitted Properly co <br /> ; <br /> APPLICATION ; <br /> ,r Non-Transferable;Revocable,and Suspendat SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) �4L3��4[f'� ?1 C1,��r Address 373 P <br /> Address Soil <br /> : Owner �! rj lT't <br /> i <br /> j Firm Partners,Addresses and Telephone Numbers Emergency Telephone No, <br /> Business Telephone No. 3G 6 + <br /> Contractor Licence No: "M pate <br /> i Applicants Name (Print) j�`r I Z <br /> lrlc geA <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 p Disposal Sites <br /> Description(Make/Yr., Color) I <br /> IhCAL. License No. CAL. License Renewal No. <br /> Serial No. <br /> Capacity i 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 /> iI <br /> No. of Chemical Toilets Stored <br /> 3. M PERCOLATION TEST e <br /> � R.S.or R.C.E.No. _!t g 3 <br /> R.S.or R.C.E.Name <br /> Test Date/Time <br /> Test Location A4,ll(so y ► ;hjEs�il gr All LA• 8$ -1 J41l;r* 8$62 <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location 'I <br /> Owner I Address <br /> El SEPTIC TANK El CESSPOOL 13LEACHING FIELD 13SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11 PERMANENT ❑ TEMPORARY 11 NEW ❑ REPAIR ❑ OTHER <br /> 5, ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction I Disposal Site <br /> No. of Units i Equipment Storage/Cleaning Location(s) <br /> RECEIVED <br /> 6. P PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name 11 <br /> :6 MAY 10 J <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity ENVIRONMENTAL HEALTH <br /> 7. ❑ LAUNDRY For July 1, -iJune 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. PERMITISERVICES <br /> ❑ DRY CLEANING,Chemicals Used/AmounVMO- person <br /> ! thttintlteperlermanceoflh work for which INS Pirmltisissit+�.'shallnotemployany <br /> 11on++swnst erMesr+rda4+nC! <br /> ft;awn p Cafitarl:ri <br /> Oil such f�gnM as to bee"So 4C Illafkft1311'a��s �t certify that is fila pelta*mance at the wsrk for which this permit�issued,I shall <br /> Cprelaegl�! I ^^8 « Sill idsw� eaftir� yrs �` <br /> sorts subieq to vrvytcman'a tomDmatmu laws of Califsrniii <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, rules and regulations of the San Joaquin Local Health District. iiU6 <br /> Cltfl 1 <br /> APPLICANT'S SIGNATURE X 99 <br /> rXr <br /> i� e�� <br /> FOR DEPARTMENT USE ONLY �cj+L / <br /> ;_. July 1<�;�&Received By July 31 <br /> Fee Is Due' ❑ ANNUALLY, ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 3 y REMIT <br /> BASI BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> E EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS �p <br /> PENALTY <br /> OTHER <br /> OTHER °I <br /> r ��_15 / <br /> Received by Date <br /> Receipt No. Permit No. Issuance Date Mailed Delivered <br /> E.HA2ELTQN AVE.,P.O.Bos 2049 STOCKTON,CA <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br /> 11601 <br /> i 1 <br />