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Applications Will Be Processed When Submitted Properly Completed- Be Sure To Sign I ne Appllcarlon. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> `Lll. <br /> LIQUID WASTE <br /> Application is reby made to car on business in the'uris�t Ictional area of the San Joaquin Local Health Distr t <br /> 7G_ .2e j )k2f d' Address / '? 7 <br /> Business Name ( A) oa <br /> Owner Address <br /> r <br /> Firm Partners,Addresses and Tone Number <br /> eleph <br /> I Business Telephone No.— dw Emergency Telephone No. <br /> a Contractor Licence No. Z a" - <br /> � <br /> Applicants Name (Print) "t phi -9- Title `DS Date <br /> Please check Appllcable-Category(1-7) and Fill In the Required Informatlen <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) - <br /> ' For July 1,1 ' -_ June 30, 1-9 Disposal Sites <br /> Description(Meke/Y .,Color)"., CAL. License Renewal No. <br /> -Serial No. CAL.License No. <br /> Capacity •!� Gal.,Weights&Measures No. -E <br /> r ~ <br /> ' <br /> Equipment ipment Parking'Address tr, r. <br /> 2.`!:.'PUMPER YARD t t!e <br /> For July 1,1 June 30,195 c <br /> ' No.of Vehicles Stored <br /> .No. of Chemical Toilets Stored 1 j <br /> 3. ❑ PERCOLATION TEST R.S.or R.C.E.No. <br /> R.S.or R.C.E. Name <br /> ' IF <br /> tion <br /> Test Date/Time <br /> Test <br /> 4. I SANITATION PERMIT <br /> Job Address/Lo Ion, <br /> ,�„�, Gc Address <br /> Owner ❑ PACKAGE PLANT <br /> I$SEPTIC TANK;j ❑ CESSPOOL LEACHING FIELD ❑ S�EPAGE PIT 11 OTHER <br /> ❑ PERMANENT f C3 TEMPORARY ❑ NEW C9'REPAIR <br /> 5, ❑ CHEMICAL TOILETS For July 1,-June 30, 19 - - <br /> Type Construction Disposal Site <br /> No.of Units Equipment Storage/Cleaning Location(e) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 Where Certified <br /> ' Operator Name <br /> Plant Location i .. fJ <br /> No.Units Served <br /> Plant Capadhy, <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/AmounVMO. <br /> ' I hereby certify that I have preparedYthis application and that the work will be done in accordance withthis Joaquin County <br /> ' ordinances,state laws,and rules a Iregulations of.the an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ) <br /> -a <br /> I <br /> FOR DEPARTMENT USE ONL'M <br /> Fee-Is Dae:❑ ANNUALLY' 13 Pat UNIT ❑ PER SITE ❑ EACH Y �❑ January 1&Received ByJanuary 31 ❑duly 1 a Recel REh11TuIy 34 <br /> 41 BILLING REMITLANGE,... 3•...Y1 S— A UNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE <br /> REMITTED AMOUNT <br /> FEE <br /> r ) <br /> ' PRORATION �w <br /> PLUS <br /> PENALTY <br /> .r <br /> OTHER / <br /> GTHIER , �,•.. - <br /> M LIA-AW <br /> Data Receipt No. Permit Na. laeUa a Dete M led Delivered <br /> Reeelved by 1801 E.HAZELTON AVE.,P. .Bow 2009 STOCKTON,CA 95101 <br /> APPLICANT-OETURN'ALL COPIES TO.. ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> r �+ <br />