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_ teteu, va _ .- - - v <br /> Applications�Will Be Processed When Submitted Property Comp <br /> ��► APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE (I <br /> ? y <br /> ' ENVIRONMENTAL HEALTH 0 PERMIT � <br /> i . LIQUID WASTE <br /> APpticatiop is ereb}�made tolC�ar[r�on business in the urisdictional area of th San Joauin,Local Health District _ <br /> �J-rf—�r- Address� <br /> Business Name (DBA) — — _ Address— <br /> Owner_ - - - - - -, - - - - - - - - - - - - - - ----- - -- <br /> Firm Partners, Addresses and Tete hone Numbers_ — — — - Emergency Telephone No.— <br /> aBusiness Telephone No. _ 2 <br /> I Contractor Licence No. -Ty — Date <br /> �/ Title os� <br /> �— — — -- <br /> fApplicants Name (Print) <br /> Please check Applicable Category(1-T)and Fill in the Required Information <br /> r i. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> p —— --—— —� -- — <br /> I For Jul Disposal Sites <br /> 1, —---June 30, 19 — -- <br /> —� <br /> Description(Make/Yr.,Color)—;'— — —--- CAL. License Renewal No. ----—— <br /> CAL. License No. — <br /> Serial No. <br /> — — — — Gal..Weights &Measures No. <br /> Capacity_ — <br /> Equipment Parking Address - <br /> 2. ❑ PUMPER YARD <br /> For July l,_ -- June 30, 19J - - - - --_- - -- -- -_-- - - -_ 0 <br /> No. of Vehicles Stored - <br /> - — t <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST f _ _ R.S.or R.C.E.No. --—— — <br /> R.S. or R.C.E. Name �1— — — <br /> ill Test Date,'Time_ <br /> Test Location _ <br /> a; JO SANITATION PEA i7 ' <br /> Job Add r s/ ocation_ - , <br /> I �j -I� l}.� �� — Address <br /> Owner_llll LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ? $1 SEPTIC TANK ❑ CESSPOOL ❑ REPAIR ❑ OTHER <br /> PERMAfJENT <br /> ❑ TEMPORARY ® NEW <br /> 5• ❑ CHEMICAL TOILETS �or July 1,-June 30, 19 — — — —— — — — — — —— — — — <br /> I _ _ Disposal Site — <br /> Type Construction— — Ib <br /> — — — — Equipment Storage/Cleaning Location(s)- <br /> No. of Units — <br /> —(i <br /> g, 11 PACKAGE TREATMENT PLANT For July 1,-June 30, 19 — — — where Certified — — — — — — — — <br /> Operator Name Z <br /> Plant Location - II — —— — No. Units Served <br /> �. Plant Capacity — <br /> 7. ❑ LAUNDRY For July 11'-June 30, 19 <br /> SIZE'. 11 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/MO. <br /> e with San Joaquin County <br /> I hereby certify that I have prepared this application and that the work will be done in accordanc <br /> ordinances, state laws, and rules and regulatio s of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> II FOR DEPARTMENT USE ONLY <br /> Fee Is Due [I ANNUA"LY ❑ PER UNIT 1:1 PFR SITE ❑ EACH ❑ January 1 &Received By January 91 ❑ J.ny 1 8 Receiv REMITBY u1y '1 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ]BASE EXPANATION DATE DATE REMIT AMOUNT <br /> L <br /> FEE <br /> PRORATION — <br /> __ --I- -� <br /> ESS <br /> PLUS <br /> PENALTY <br /> — <br /> OTHER <br /> OTHER -7 <br /> Issuance Date ailed ehvereO <br /> - - Receipt No. Perna No. 1 <br /> Received by Nti Date 1fi01 E.NAZELTON AVE,P.O.Box 2009 STOCKTON,CA <br /> � <br /> APPLICANT—R@TURN'll LL COPIES TO: ENVIRONMENTAL HEALTH PERMITiSERVI — <br />