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APPLICATION <br /> or Non-Transferable, Revocable, and Suspends SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT / <br /> ve <br /> LIQUID WASTE <br /> Application isreby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) , •L 1-t- '< Address <br /> MIS`Owner- Address <br /> u Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. 'p 'C_-rT_ .6-1 Emergency Telephone No. <br /> ?Contractor Licence No. ,2 a4`�SI�, <br /> j Applicants Name (Print) 04-zz—, A z45W Title �«--�+u�' Date ,�--�`��� ^� <br /> Please check Applicable Category (1-7)and Fill In the Required Information <br /> r 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 6 <br /> For July 1, June 30, 19 Disposal Sites . <br /> Description(Make/Yr.,Color) S <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> r <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> r For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored _ <br /> r 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. ❑ SANITATION PERMIT Cp <br /> .,Job Address/Location A cs'ov <br /> O0 �� Aid S� Address <br /> 1fa <br /> SEPTIC TANK 13CESSPOOL LEACHING FIELD 11SEEPAGE PIT 0 PACKAGEE PLANT <br /> r ❑ 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 /> r 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location - <br /> r Plant Capacity - No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 - <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> Nee ❑ DRY CLEANING,Chemicals Used/Amount/Mo. - <br /> Nee <br /> I hereby certify that Ihave prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regul ions of the San,Joaquin Local Health District. <br /> r APPLICANT'S SIGNATURE X Gd y <br /> 1 <br /> lee <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 /> BILLING - REMITTAN $ <br /> BASE EXPLANATION ..DAMOUNT DUE CHECKED <br /> ATE OAT REMITTED <br /> AMOUNT <br /> � Q <br /> FEE m <br /> LESS <br /> PRORATION - <br /> bee PLUS <br /> PENALTY <br /> OTHER <br /> r -.-OTHER <br /> �3a� gli� l� l <br /> Received by Date Receipt No. Permit No. rssuam;ebata Mailed Delivered <br /> `y APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.80.2009 STOCKTON,CA 95201 <br />