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ApplicationsWill Be Processed When Submitted Propedy Completed.Be Sure to Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> !� ENVIRONMENTAL HEALTH PERMIT <br /> I� LIQUID WASTE <br /> Application is hereby made to-carryon business in the jurisdictional areaef•the S_a aquin Local Health District <br /> �� ° <br /> ,r,Business Name(bBA) Address_ l Gyle _.., , •- <br /> Owner— i�.--=�„� .� Address _ l <br /> Firm Partners, Addresses and Telephone Numbers I <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. � r �• F• 1 <br /> Title-�L Date i <br /> Applicants Name(Print) <br /> Please check Applicable Category,(1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT;REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, :"June 30,-1'9' — -Disposal Sites- - - <br /> Description(Make/Y.r.,Color) <br /> Serial No- CAL,License No. _ CAL. License Renewal No, 1 <br /> Capacity it Gal.,Weights$Measures No. <br /> a <br /> Equipment Parking Address_ I <br /> 2. ❑ PUMPER YARD a <br /> For July 1, 'June 30.19 <br /> No.of Vehicles Stored <br /> No.of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST '« �� : T `,` f <br /> _5_. <br /> Testi Loc; tion Q _ Test Date/Time zb <br /> 4. SANITATION PERMIT sr' �s X Y <br /> Job Address/Lo on 1 <br /> Ow nr Address 7.9115a7- G' <br /> SEPTIC TANK ❑ CESSPQQIn EACHING FIELD ❑ SEEPAGE PIT ❑ 'PACKAGE PLANT iif p <br /> PERMANENT ❑ TEMPORARY NEV! 13 REPAIR <br /> 11 OTHER �J <br /> s. ❑ CHEMICAL TOILETS For J31 uly 1,-June 30, 19 _ <br /> )e Construction !. �_W.,� Qtsposal•Site <br /> ,.o.of Units .7 Equioment•Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PT For Julyl,-June 30, 19. ' <br /> Operator Name ,,F i Where.Certified <br /> Plant Location <br /> Plant Capacity r !� / No.Units Served i <br /> 7. ❑ LAUNDRY For July 1,-Junel30, 19 tT-- - <br /> SIZE: ❑ Less Than,1,000 Sq.Ft_, ❑ More T_ h_an 1,000 Sq, Ft. <br /> 0 DRY CLEANING,Chemicals Used/AmountfMo. <br /> yin <br /> l hereby certify that I have prepay d th+s application and�hat thewnl�rk will be don> titr�agaYortidan�e with � �aounty <br /> ordinances,stale laws,anc(�rules.a d ul s th San,f3oaquln Lgce6t Health District.^ f <br /> APPLICANT'S S9GNATUREX •s •-� - ^- <br /> I! <br /> -. ...,. : TL•,t� EPARTNIENT USE.ONLY , <br /> R 7'1i`� i�� 31 ❑Jul S S Received By JWy 31 <br /> Fee is Due: ❑ ANNUALLY I'❑PER UNIT, Cr PER SITE ❑EACH ❑ January 1&Received By Jarfu@ry! y RE IT <br /> w AEMiTTANCE' S AMOUNT DUE CHECKED.vw" <br /> BASE lv=fiX�LA t47 .f DATA{ {_ ;DATE EMITTED AMOUNT <br /> 1 , 1 <br /> FEELESS <br /> PRORATION '` f <br /> PENALTY <br /> OTHER 4 ;) a. :.�`o- 4, 'l t _ _ ,,,..+...*1'• <br /> OTHER. y li <br /> Received by Date s Reoeipt No. •Permit No. ssuan Date Mailed Delivered <br /> _71 APPLICANT—RETURN ALL COPI <br /> ES TO ENVIRONMENTAL H£ALTH PERMIT/SERYICES 1661 E.HAZELTON'AVE.,P.O..Box 2009 STOCKTON.CA 95241 <br /> ? r ..-- — i <br />