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P_ n Submitted Property Omp sated, tae owe <br /> App <br /> lications Will Be Processed Whe <br /> C APPLICATION <br /> ll , (For Non-Transferable,Revocable, and suspendabte) SEPTAGE <br /> V <br /> ENVIRONMENTAL <br /> WASTE TH PERMIT <br /> Ll <br /> to carry on business i he jQU urisdictional area of the San Joaquin Healt 0'strrr ��� — — <br /> APPlicati s h-�er^eby m ,Q (�l CL� Address_�©--- <br /> Business Name (DBA) Address��O S1- <br /> k - - - - <br /> J Firm partners,Addresses and Telephone umbers_.----- — Emergency Telephone No. — — <br /> foS. <br /> /la — — -- — -- �.� <br /> CL Business Telephone No.—....--- ._ - - --' <br /> //// ——— — Date <br /> �Contfactor Licence No. 3 < —T l� Title $ <br /> -- <br /> � < APpli�'antS=�•lamel�rtnt)>��_.. —.____- y <br /> Please check Ap�libat a Category(1-7) and fill in the Required Information <br /> ❑,DUMPER VEH16LE,PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> c. .����• ` -` '' Disposal Sites <br /> For July 1. June 30. 19 —— — "--� <br /> — — -- — <br /> Description(Make/Yr- Color)_...—.___ — CAL.License Renewal No.— — <br /> 1 Serial No. -- — — —_— --_— — <br /> CAL. License No. <br /> Capacity — — — — Gal.,Weights &Measures No. — <br /> E -- -- - -- <br /> Equipment Parking Address -- <br /> 2. ❑ PUMPER YARD <br /> r For July 1,___ June 30.19 <br /> 1 No.of Vehicles Stored <br /> M No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST —y <br /> R.S. or R.C.E.No <br /> R.S.or R.C.E.Name <br /> _ Test Date/Time.— <br /> Test <br /> ate/Time.—Test Location <br /> r 4. g SANITATION PERMIT - - — (�C�tJ�Q / e.#4 — <br /> Job Addressil-ocation _ <br /> Address1 - <br /> Owner � J�li7/1lI — 13PACKAGE PLANT <br /> ❑ SEPTIC TANK (3 CESSPOOL LEACHING FIELD SEEPAGE PIT O OTHER <br /> PERMANENT <br /> ❑ TEMPORARY Q NEW REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> — —_--_ ',----- <br /> Disposal Site — ——— — <br /> Type Construction — <br /> No.of Units .—--- =— -- Equipment StorageiCleaning Location(s)e- <br /> ` 6. 11 PACKAGE TREATMENT PLANT For July,1„ June 30. 19_ Wnere Certified _ --- — — <br /> Operator Name <br /> Plant Location —._.—.—_.--_--_-- <br /> No.Units Served _ —— <br /> Plant Capacity <br /> L 7. Q LAUNDRY For July <br /> 1, -June 30,-19=- =- <br /> F SIZE: E3Less Than 1,0oo Sq, Ft., 0 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/MO. =--�-� 1 <br /> A ` <br /> t Prepared this application and that the work will be done in accordance with San Joaquin Counly <br /> L heretiy certify that'1'tTave <br /> ordinances,state laws,O�Je4sand regula ions of the an Joaquin Local Health District. <br /> k - <br /> APPLICANT'S SIGNATURE X --- <br /> k * �,t. ..a FOR DEPARTMENT USE ONLY <br /> I, t /�:� t <br /> J�,, 'YERStTfi ❑ EPCIt,�- ❑ January;�,-.Recewrf By January'.37� ❑ JWy 5&flece+Y�MI7By "y 31 <br /> Fee is Due: ❑ ANNUALLY f=❑ PER-UNIT ^N ,, _. —_ —yam- _ -' <br /> —( T <br /> LING— �RFMITSANCE"�� REMIT <br /> �r� AMOUNT DUE CHECKED <br /> EBASE I f_XPLANATI N DATE DATE REMfTTtO AMOUNT <br /> FEE <br /> LESS <br /> PLUS 1 _-� ` <br /> �'..— <br /> PEliAL1:Y <br /> { OTHER II I — <br /> 0711ERt <br /> f ..—.-- Issuame Date Mailed Del <br /> -------- -- i ed <br /> Permil NG <br /> Recei.ed by — Date Rece�Gt No., . <br /> 1607 E.HA2ELTON AYE.,PA.aoz 2009 STO-KTON,CA 96$,0 <br /> — APPLICANT-RETURN ALL COPIER TO: _ENVIRONMENTAL HEALTHRM;T`�RV ES t -� - . _ - ` <br />