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At-r-LII#H 1 IU1V <br /> (. Ion-Transferable,Revocable,and Suspendable) SEPTAGE <br /> __.ENVIRONMENTAL HEALTH PERMIT _-----_- <br /> LIQUID WASTE <br /> Application is herebymade to carry on business in the jurisdictional area of the San Joaquin Local Health District t�-�� <br /> OF Business Name (DBA) WON ,- Er1GAPSER5 INC. Address— z1� N ' r�UNrErL • ST'Ocr— y N <br /> i Owner C+ • It RhNCE UJ ON G- Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> G.a. Business Telephone No. 4' '� O 3 Emergency Telephone No. <br /> Contractor Licence No. - �'1 <br /> Applicants Name(Print) C Ck4RNC� ILArOt�1G Title �R'ES• Date �S <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 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. K PERCOLATION TEST A .W•� <br /> R.S. or R.C.E. Name Cr - Cl�A NCE. O N Cr- R.S.or R.C.E.No. <br /> Test Location 'L777 u E• F F&WCtj &NIM? Test Date/Time Ar <br /> 4. 11 SANITATION PERMIT P m 8-L--3'L �E, TO 9M ir�TO C.0. <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER V <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified v' <br /> Plant Location <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 /> I hereby certify that I have preparedt 's a a ion and tha h w rk will be done in accordance with San Joaquin County <br /> ordinances, state laws,and rules e u n the San a ui cal Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY ` <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 3 Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> GATE DATE REMITTED AMOUNT <br /> FEE � <br /> LESS Z <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> � <br /> Received b I Date Receipt No. Permit No. Issu ce to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZ N AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />