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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION " <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Namme- (DBA). '�� e C e Xe.-02-1-C' Address J921 T.404�10/ <br /> a Owner— f��A/J'�P�(1C' �l�iy�� 5' Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. 2 2-471 _.._ Emergency Telephone No. <br /> Contractor Licence No. <br /> LAppiicants Name (Printf EJ Title Dated <br /> Please check Applicable Category(1-7) and Fill in the Required Information CL;a,t ,t«L S SEFT;C x }. <br /> 1. 11PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 2e5 So. Oro SSERVICESt?ckic:,, Calif. 952{15 . <br /> For July 1, June 30, 19 Disposal Sites f h.f �_.o <br /> . ��—�Cdt7�i <br /> Description(Make/Yr., Color) - <br /> Serial No. CAL. License No. CAL. License Renewal No. C� <br /> t -- <br /> Capacity Gal.,Weights & Measures No. r <br /> Equipment Parking Address _ <br /> t 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 /> f Test Location ' Test Date/Time Q <br /> 4. Cl SANITATION PERMIT _ <br /> .Job AddresslLo a ' n 7" <br /> ner Address -� <br /> SEPTIC TANK ❑ CESSPOOL ArLEACHING FIELD •SEEPAGE PIT El PACKAGE PLANT <br /> X PERMANENT ❑ TEMPORARY PeNEW ❑ 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 /> 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 /> i 7. ❑ LAUNDRY For July 1, -June 30, 19 g�1 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft:, ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. \ <br /> i <br /> Uf <br /> k <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, state laws, n r nd regulations of the San Joaqu' Local Health District. <br /> ✓CG'u-2- GLr^,i� ilCf'S �i 'i C :r <br /> APPLICANT'S SIGNATURE X SERVICE <br /> - <br /> [uJ So, r0 2;1S.c-i tt-u! �w f. 95205 <br /> Ph.463-3209 Ca f':a ior's Lic.J26717.0 <br /> FOR DEPARTMENT USE ONLY <br /> Fee WDue: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 0 EACH ❑ January I &Received By January 31' ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT,, -. <br /> BASE. EXPLANATION � <br /> DATE DATE REMITTED AMOUNT OUE GHEGKED� _ <br /> AMOt7NT -' <br /> FEE <br /> 4-Ss <br /> LESS 7 p <br /> PRORATION f4 2, <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER I <br /> r. <br /> 1 �a �3 0 7(1.3 r pb <br /> Received by C Date I Receipt No. Permit No. ssuance ate Mailed Delivered <br /> APPLIC T=RETURN ALL COPIES TO: ' 'ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA.95201 <br /> 't�� —-P'GaEp;k <br />