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rr. �..�.• v.,. �� r .�..,..,..Lr r. rU r�u�r u:utb r vYe rJ Lu erl V. u ... ,.. Jryri ru_ [vyy u..altui:" <br /> APPLICATIONr <br /> L (FIjll,,,,,,,On-Transferable,Revocable,and Suspendable) tiJ <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SEPTAGE <br /> LIQUID WASTE � <br /> ( Application l hereby made to carryon business in the jurisdictional area of the San oaquin Local Health District <br /> 111"siness Name (DBA) �/ /, rf/LGA= Address <br /> Owner Address <br /> I, -m Partners,Addresses and Telephone Numbers _1 - <br /> I`Isiness Telephone No. Tf`��y� / Emergency Telephone No. <br /> Contractor Licence No. <br /> P�plicants Name (Print) r /`L-L.GG ik Title /_9.✓"Fu o 2.- Date <br /> 'ase check Applicable Category (1-7) and Fill in the Required Information <br /> Ilm ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> d :ascription(Make/Yr.. Color) <br /> Lrial No. CAL.License No. CAL. Lie -ae Renewal No" <br /> Capacity Gal.,Weights &Measures No. <br /> I luipment Parking Address <br /> C1PUMPER YARD <br /> 0'r July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> L` of Chemical Toilets Stored <br /> ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.G.E.No" <br /> Lst Location Test Date/Time <br /> ❑ SANITATION PERMIT *33 /. _ D;;11 _ G <br /> Job Address/Location 6 IO /G G _ - IU <br /> 6 <br /> owner <br /> Address <br /> EPTIC TANK ❑ CESSPOOL EACHING FIELD ,❑, SE/EPA. ❑ <br /> GE PIT PACKAGE PLANT <br /> L PERMANENT C1 TEMPORARY El NEW I�'HEPAIR ❑ OTHER 7 <br /> 5. ❑ CHEMICAL TOILETS For July 1.-June 30, 19 a� <br /> Lype Construction Disposal Site <br /> o. of Units Equipment Storage/Cleaning Location(s) n <br /> 6_ ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Aerator Name Where Certified <br /> Lr ant Location <br /> Plant Capacity No.Units Served <br /> 7" ❑ LAUNDRY For July 1, -June 30, 19 <br /> ZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. FL <br /> �I DRY CLEANING, Chemicals Used/Amount/Mo. <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, slate laws,and rules and re a s of the San Joaquin Local Health District. <br /> ILPPLICANT'S SIGNATURE X t` ✓�' ��'Ci <br /> FOR DEPARTMENT USE ONLY <br /> TI Fee IS Due: 13 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 d Receive0 By January 31 ❑ July 16 Received By July 31 <br /> BILLING REMITTANCE ! REMIT <br /> j BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE C$1 �� <br /> LESS <br /> PRORATION <br /> 4 <br /> PLUS <br /> PENALTY <br /> {[ OTHER <br /> • OTHER <br /> d <br /> ! Received by_DateReceipt NO. Permit Nol Issuanc¢pale Mailed Delivered <br /> L !` APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 101 E.HAZELTON AVE.,P.O.Bm IOW STOCKTON.CA 95"1 <br />