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APPLICATION <br /> or Non-Transferable, Revocable, and Suspendiy� SEPTAGE <br /> �. ENVIRONMENTAL HEALTH PERMIT" <br /> LIQUID WASTE <br /> Application Is he by made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> 4 Business Name (DBA) / e Address <br /> z Owner Ell 1, 6 6`"40—' Address <br /> a <br /> Firm Partners, Addresses and Telephone`N-u—tubers <br /> Business Telephone No. T�i�y 2S Emergency Telephone No. <br /> "01 Contractor Licence No. <br /> 4 Applicants Name (Print) 4. Ly15zdG4se Title d�. Date <br /> Please check Applicable Category(1-7)and Fill In the Required Information <br /> Ila, 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) �- <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(MakeNr.,Color) <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 /> rala 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 /> ❑ SANITATION PERMIT <br /> G s/ iAAV'547A-" 2 <br /> � Job Address/Location ^7 Al <br /> �Ow r - b Address `�' �>✓ � <br /> PTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> r ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER G <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 - G <br /> Type Construction Disposal Site C <br /> No.of Units Equipment Storage/Cleaning Location(s) - <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location _ <br /> Plant Capacity - No.Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,DOO Sq. Ft., ❑ More Than 1,000 Sq. Ft. _ <br /> ` ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r <br /> 1 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 rules and regulations of the San Joaquin Local Health District. - <br /> APPLICANT'S SIGNATURE X <br /> r <br /> ` FOR DEPARTMENT USE ONLY , <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT. ❑ PER SITE - - ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE 1 AMOUNT DUE CHECKED <br /> DATE DATE, _ REMITTED AMOUNT <br /> h. <br /> FEE dL45 Owl . Q <br /> LESS < <br /> PRORATION <br /> a. PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Dale Receipt No, Permit No. 1 upnce Date Mailed Delivered <br /> ` APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Baa 2079 STOCKTON,CA 95201 - <br />