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Applications Will Be Processed When Submitted Properly Completed. Be Sure f , <br /> APPLICATION <br /> ,., (For Non-Transterable, Revocable,and Suspendabie) SEPTAGE t <br /> ENVIRONMENTAL HEALTH PERMIT 1k <br /> LIQUID WASTE k <br /> is hereby made to carry on busine <br /> ss in the jurisdictional area of thew© <br /> Applicationo u�Local Health District — — <br /> -1 Address�� F-- <br /> F_ <br /> Business Name (DBA-)—l^ni t'S �� � 1G <br /> �D ` =`s <br /> a <br /> Owner—Fr-'n, Address <br /> - umbers�J� <br /> cJ Firm Partners. Addresses and TelephonetOEmergency Telephone No, n ' <br /> CL <br /> Business Telephone No.—3kY <br /> Contractor Licence No. — (L>p Date— =—+�= —r <br /> — Title �) ' <br /> ApplicantsNail (Pint) -' <br /> Please check Applicable-Cat ory(1-7)and Fill in the Required Information <br /> 1 ❑, TWPERNEHICLE.PERMIT REGISTRATION (POR EACH VEHICLE) <br /> For July 1;,. <br /> _ June 30, 19 — - Disposal Sites <br /> Description_(Make/Yr.,Color)---- -- f CAL.License Renewal — <br /> _ CAL. License No. —_— <br /> Serial <br /> Cagscit _ Gat.,Weights& Measures No. <br /> Y -- -- __ <br /> _ — } <br /> Equipment Parking Address ---- <br /> 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 R-S.or R.C.E.No. _•_ --- -`�— <br /> R.S.or R.C.E. Name , Test Date/Time <br /> Test Location ``p <br /> 4. LY SANITATION PERMIT �/��S t �fd-fie-- '�� <br /> z d_ _ _ _ 5d e <br /> Job Add — t l Address-- �f — <br /> Owner ❑ LEACHING FIELD -SEEPAGE PIT ❑ PACKAGE PLANT <br /> 13SEPTIC TANK ❑ CESSPOOL PAIR 11 OTHER <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW (�1 <br /> 5• ❑ CHEMICAL TOILETS For July 1,-.lune 30, 19 <br /> ( Sitef — <br /> E Type Construction _Disposal <br /> — -- — Equipment Storage/Cleaning Location(s) <br /> No.of Units <br /> 6. ❑ PACKAGE TREATMENT PLANT For July},-June 30. 19 - — Where Certified <br /> Operator Name <br /> Plant Location --- �"� _-- <br /> _ No. Units Served <br /> Plant Capacity --� <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 More Than 1,000 Sq. Ft. - <br /> SIZE- ❑ f e ❑ Less Than 1.000 Sq. Ft-, , e <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. a <br /> Nc:s+e^•a+cwc-!r-ersad�C,enl-, 'ltir:g :�;,t:`siho;o!lowing:`!!.rC!tify!`';it•!�tt�.C7C``^'!T17�,LCOi.t`:°44'oiE::l;elYriCht41509[Ill!ti51:5Us'd.�3`'311nC?EF'INI�.yarypEr50r1 <br /> ='3`- <br /> jr,sLicit n7a"^i<lF,!°beeorre;ut:jEC?tG var.•rk`:nan's::o!npen anon IaHs'of�ali li�nia.•- - !Shull <br /> Cen.ra t1r's i ing or s'-:t-catuzrti 3'3iyna'tu certifies the tol:oWing: "t ceitily That in the performane'[0i the work for WhlCtl%iS_per,Tif IS issued.! <br /> l employ porsans subject is v.'a[�rluli 5�p Ipeilsotlafis oCCaliionll�a"t <br /> s <br /> I hereby certify thahave prepared this-application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws- d rules an re lations of the San Joaquin Local Health District. <br /> - - — <br /> APPLICANT'S SIGNATURE X"` - <br /> l <br /> I ,� FOR DEPARTMENT USE ONLY <br /> a h 51 ❑ July 1 &Received By July 31 <br /> { >U PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January <br /> t REMIT <br /> Fee Is Due: ❑ ANNUALLY ❑ $ AMOUNT DUE CHECKED <br /> BILt_ING REMITTANCE <br /> fI DATE REMITTED _ AMOUNT <br /> r ti♦ �'•' -7 'I 'BASE <br /> '4i EXPLANATION DATE <br /> FEE` <br /> LESS A � <br /> PRORATION <br /> PLUS 1r V�\U" <br /> PENALTY <br /> OTHER <br /> OTHER ---- t <br /> I <br /> 5 t.� � —`— ssua a ate Mailed Dative d <br /> Permit No. 95201 <br /> Received by Date i Receipt No. - 1601.E.HAZELTON AVE.,P.D.ao!:2009 - STOCKTON,C <br /> l, APPLICANT—RETUS N ALL COPIES f0: ENVIRONMENTAL HEALTH PERMIT/6ERVIC ` '�� <br />