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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> 4 (For Non-Transferable, Revocable, and Suspendable) SEPTAGE / <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> / <br /> LIQUID WASTE / <br /> Application i ereby made to ca on business in the jurisdictional area of t San Joaquin Lo al Health Distr' t <br /> H Business Name (DBA) — fS Address f SLYNA <br /> aOwner .. Address n , <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. ��Q = :Emergency Telephone No. ` <br /> a Contractor Licence No. - <br /> �Applicants Name (Print) b Title 72fs T Date <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, 19 -Disposal Sites - <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity' '-Gal.,Weights &Measures No. <br /> Equipment Parking Address `' <br /> 2. ❑ PUMPER YARD s # �- <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored { <br /> No. of Chemical Toilets Stored .. 1 <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 21 <br /> 4. ❑ SANITATION PER ..I/T•�, } A <br /> Job Addres ocation t1 -d Y d a A , de <br /> �Ew N <br /> O -ner N )} L Address eb i Agy 114 NP <br /> SEPTIC TANK SSPOOL LEACHING FIELD ,SEEPAGE PIT ❑ PACKAGE PLANT .4 <br /> PERMANENT ❑ TEMPORARY TNriNEW ❑ REPAIR i�C] OTHER <br /> S. ❑ CHEMICAL TOILET,Si„ForJuly 1,7-J0ne 30,"1'9'"" „ <br /> Type Construction ""' -:.Disposal;SiteNo. 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 CapacityNo. Units Served ' <br /> 7. ❑ LAUNDRY eFQr'July 1, -June 30, 19 <br /> l SIZE: ❑ Less Than.1,000 Sq. Ft;, 13More Than 1,000 Sq. Ft. 1 <br /> t �• <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. .. <br /> V <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, and r s and regulati ns,of t n Joaq'n Local Health District. r <br /> APPLICANT'S SIGNATURE X <br /> f - ' • i FOR DEPARTMENT USE ONLY <br /> n <br /> Fee Is Due: El ANNUALLY' .1 ❑'PEI NIT ❑ PER SITE ❑ EACH ❑ January'Q&Received By January 31 July 1 A Received By July 31 <br /> BILLING - REMITTANCE . REMIT ' <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE r' DATE REMITTED p I AMOUNTlox ' <br /> s tf� <br /> FEE 4 <br /> LESS <br /> PRORATION °y . "•" ['l ... - i VF- <br /> 1'•' •l'� <br /> PWS <br /> 4 <br /> PENALTY <br /> OTHER aDa <br /> OTHERReceived 6y e,..-.� 'Receipt No.. Permit o. . ..,., ssu ce Ua Mailed Delivered r <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1691 E.HAZEL N AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />