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APPLICATION <br /> or Non-Transferable, Revocable;and Suspends <br /> s,. SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT-, <br /> LIQUID WASTE <br /> Application is hereby madq4o carry on business in the jurisdictional area of the San Joaquin Local He <br /> yBusiness Name (DSA) n ue� Address /�� <br /> Owner Address�/ 70 S_ U LAIr <br /> M Firm Partners, Addresses and Telephone Numbers <br /> iA. Business Telephone No. �L ��� G Emergency Telephone No. <br /> Contractor Licence No. ,? 5 <br /> Applicants Name (Print) ��/ t � �. l-t Title 6? Date !:2Z 2- z �� T <br /> f Please check Applicable Category (1-7)and Fill in the Required Information <br /> I 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites _ h <br /> a <br /> I Description(Make/Yr., Color) r' <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, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E.No. <br /> Test Location Test Date/Time <br /> 4. q SANITATION PERMIT <br /> Job Address/Location _ /� .7 r_-4, <br /> Owner - ---- �" �- � �� Address <br /> SSE TIC TANK CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> i tld`PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> B. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> 4 Plant Capacity No. Emits Served <br /> If 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/Amount/Mo. <br /> 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, and clipygd regulatior of he S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X G"/� <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 b,Received By January 31 ❑.July 1&Received By July 31 <br /> I <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE FEE 'l 14 t� <br /> LESS ' <br /> PRORATION IIf ,j <br /> I PLUS I -1 <br /> PENALTY ( V <br /> k1 <br /> [ OTHER <br /> IIIc OTHER <br /> Received by Date Receipt No. Permit No. issuance ate Mailed Delivered <br /> i - <br /> APPLICANT—'RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES t601 E.HAZELTON AVE.,-P.O.B a 2005 STOCKTON,-CA-95201 <br /> - <br /> A66e�( � Gumoa9 " �' <br />