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APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> `Business Name (DBA) LC=cn�j F��;,v�/ Address " <br /> i Owner = c Address <br /> " Firm Partners, Addresses and Telepho a Numbers <br /> Business Telephone No. �3 y-J /�' Emergency Telephone No. <br /> Contractor Licence No. AA <br /> i Applicants Name (Print) 1u.1, r/:11.(��j Title 144,�7 Date 7jn <br /> Please check Applicable Category (1-7) and Fill in the Required Information c N <br /> Lal. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) - <br /> Serial No. CAL. License No. - CAL. License Renewal ND: - -- <br /> Capacity Gal.,Weights&Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD ` <br /> xxx For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored �j <br /> a.3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name - R.SStor R.C.E. No. -- <br /> Test Location Test Date/Time - <br /> `4. V SANITATION PERMIT .4 p / <br /> Job Address/Location ��- � ,�B,Air 77k4! <br /> OwnerN' Address �� � ? <br /> SEPTIC TANK ❑ C SSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT L� <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER _ <br /> 5. ❑ CHEMICAL TOILETS Forduly4;-,Mune 30, 19 <br /> Type Construction Disposal SiteSax <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 /i, <br /> Plant Location - _ __ _ - 1 <br /> " 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.�Fi, <br /> I..❑ DRY CLEANING,Chemicals Used/Amount/Mo. - - <br /> Six, <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Ban Joaquin County <br /> ordinances, state laws, and rules and r lati ns of the San Joaquin Local Health District. <br /> s. APPLICANT'S SIGNATURE <br /> ` '- FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH :Q January.1&Received By January 31 ,0 July 1 8 Received By July 31 <br /> REMIT <br /> BILLING i REMITTANCE E <br /> BASE EXPL.@NATION _ AMOUNT DUE- CHECKED' <br /> DATE - ' 'DATE REMITTED AMOUNT <br /> FEE <br /> �F., <br /> LESS _ - _ <br /> PRORATION <br /> PLUS ... .. .. - . <br /> PENALTY <br /> OTHER <br /> OTHEfl.... .. - _. <br /> 6 Y <br /> Received by Date Receipt No. Permit No. iAsuaneA Date Mailed Delivered <br /> r APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE.,P.O.Bos 21109 STOCKTON,CA 95201 <br />