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.-.'r___---_-__ ••___ __ .__----� ....-................... ...p....� vv...r.o>ov. va vu.c .v veyn . .c�pn..ouvn. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,-and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT / <br /> LIQUID WASTE <br /> Application is h_ereby made to carry on business in the jurisdictional area-of the San Joaquin Local Health District <br /> Business Name (DBA)^T�_, /�d Lev- _ _ _ •-Address . <br /> OwnerQ R / C_ '/� Address. - ._. .. <br /> Firm Partners,Addresses and Telephone Numbers <br /> ��f <br /> Business Telephone No. '�� _7�'R , - Emergency Telephone No. <br /> _J Contractor Licence No. A2.26_6-l'��--• <br /> L Applicants Name (Print) 'Title'1 f �iiLL�✓i Title •Date A <br /> Please check Applicable Category(1-T)and Fill in the Required Information <br /> 1. ❑ 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 Na_ <br /> Capacity Gal.,Weights&Measures No. <br /> Equipment Parking Address <br /> 2: ❑ PUMPER YARD 1 <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 /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT ��yy r O <br /> Job Address/Location dl• 7 6-:2 5: (1A Al 56,OV f` <br /> Ow er' � i a/�iS S'� Address .>��%� <br /> as SEPTIC TANK ❑ CESSPOOL QKLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT J .. <br /> ❑ PERMANENT 0 TEMPORARY [],NEWJ 13REPAIR _Q,OTHER:_,L <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 = <br /> Type:Construction _ Disposhl Site <br /> No. of Units Equipment Storage/Cleaning Location(s) -_____�_ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, _June 30,`19 <br /> OperatoryName - a ('t' A; Where Certified - I <br /> Plant Location r- <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. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo, <br /> f I hereby certify thaT"1 htive"prepared"this applica lot+ot n-and that the work'411 bye done in accordance with San Joaquin County <br /> ordinances,state laws;and rules and re gul ions bf}he SanJoaquin Local Health District. <br /> 'I . -, r #- <br /> APPLICANT'S SIGNATURE X <br /> MR.DEPARTM_ENT USE ONLY <br /> Fel I9 Due: ll ANNUALLY - ❑ PER UNIT ' ❑ PER SLYE, ❑ EACH ❑ January 1 &Received ByJanuary 31 ❑ July 1&H elved By July 31 <br /> I _..� BI[].YN(3 '+ '',REMITTAN ; REMIT <br /> tt BASE EXPLANATION .DATE `• DAT REMITTED AMOUNT DUE CHECKED = <br /> F AMOUNT dt <br /> FEE t d i <br /> PRORATION f ' <br /> PLUS <br /> PENALTY - w + <br /> _OTHER <br /> r 1, <br /> Received by Date Receipt No. Permit No I ante ate Mailed Dellvered <br /> AI+PLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1901 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA SS201 ' <br />