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Applications Will Be Prn sed When Submitted Properly Completed. Be Su Sign The Application. <br />APPLICATION <br />(For Non -Transferable, Revocable; and Suspendable) _. SEPTAGE <br />ENVIRONMENTAL HEALTH•PERMIT <br />LIQUID WASTE <br />EXPLANATION <br />Application IarryonVDslness In the rlsdictional area of the pj;nn oa i t FJea strict <br />REMITTANCE E <br />Business Name (DBA) _G%�i G4� t� Address ((� <br />CHECKED <br />OF <br />Owner Address — - <br />- <br />Firm Partners, Addresses and Telepho y ie Numbers :.. <br />6 <br />.s PATE <br />a Business Telephone No. Emergency Telephone No. <br />Licence No. <br />Contractor <br />Applicants Name (Print) Title. Date <br />is <br />f <br />Please check Applicable Category (1-7) and Fill in the Required Information - �: • ;•,fir t<; <br />fj(♦1 <br />1. ❑ PUMPER VEHICLE PERMIT REGISTRATION FOR EACH VEHICLE) <br />�V <br />For July 1,'- - ' • June 30, 19 Disposal Sites -- _ <br />,:' ; <br />Description (Make/Yr., Color) .. - k' <br />Serial No. CAL. License No. CAL.'License Renewal No. <br />LESS <br />Capacity Gal., Weights & Measures No. <br />Equipment Parking Address <br />, <br />2. ❑ PUMPER YARD <br />For July 1, June 30, 19 <br />No. Vehicles Stored <br />of <br />PLUS <br />No. of Chemical Toilets Stored <br />— <br />3. ❑ PERCOLATION TEST <br />R.S. or R.C.E. Name R.S. or R.C.E. No. <br />Teocation Test Date/Time <br />4, V, SANITATION PERMIT <br />Job Address/ oc tion <br />y , k , T^ <br />Owner _-_ ��VJr{J V� LT rte' Address r z <br />OTHER <br />❑ SEPTIC TANK ❑ CESSP_OOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br />�Q <br />pp <br />❑ PERMANENT ' ❑ TEMPORARY - ❑ NEW REPAIR J40THER QfX14! pE.P <br />o(I <br />S. ❑ CHEMICAL TOILETS For July 1, • June 30, 19 <br />i <br />Type Construction � ' I Disposal Site •c <br />No. of Units t ' Equipment Storage/Cleaning Location(s) <br />� <br />6. ❑ PACKAGE,TREATMENT. PLANT, For July 1, - Junkld.`19 <br />Operator Name i - I 1 i. - `�' Where Certified �) <br />Plant Location <br />Plant Capacity I No Units Served i _ :; �• + t <br />7. ❑ LAUNDRY' For July 1, = June 30, 19 r _. <br />SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1',000 Sq, Ft. <br />❑ DRY CLEANING, Chemicals Used/AmountiMa. <br />Ir hereby,certif have prepared this application and that the work will be done in accordance with San Joaquin County <br />�thatJ <br />brdinari'c6s-Ni6 Ia*s, and rule d regulation of the S quln L c Health District. <br />APPLICANT'S SIGNATURE X `` r <br />FOR DEPARTMENT USE ONLY <br />taa In r%..-. 171 w.,.0 iei , r1 oco 1 —IT 11 PPC CITE 11 ceeu n .lanumv 1 A Rxefved Rv January 31 ❑ July 1 8 Received 8v July 31 " <br />APPLICANT -RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PFAMIT/SERVICES 1601 E. HAZELTON AVE., P.0 -1r0 -Y 2009 •STOCKTON, CA 95201 <br />REMIT <br />BASE <br />EXPLANATION <br />BILLING <br />REMITTANCE E <br />AMOUNT DUE <br />CHECKED <br />.s PATE <br />-DATE REMITIEU <br />AMOUNT <br />�'i <br />is <br />f <br />FEE} <br />,:' ; <br />0 ✓� <br />LESS <br />, <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />- <br />OTHER <br />APPLICANT -RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PFAMIT/SERVICES 1601 E. HAZELTON AVE., P.0 -1r0 -Y 2009 •STOCKTON, CA 95201 <br />