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Applications Will Be.Processed When Submitted Properly Completed. Be Sura To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> 01 ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE 9 <br /> Application is herebma on siness In the jurisdictional area of the San Joaquin Local Health District <br /> m Business Name(DBA) Address <br /> Owner Address , <br /> dc <br /> Firm Partners,Addresses and elephone Numbers_ <br /> Business Telephone No. _•Emergency Telephone No. <br /> Contractor Licence No. L, - Date � - <br /> L Applicants Name(Print) - :- L rl1 Title --cf-- <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) CAL License Renewal'No. <br /> Serial No. CAL.License No. -•- <br /> Capacity Gal.,Weights&Measures No. <br /> Equipment Parking Address-, <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> N0. of Vehicles Stored. - <br /> No. of Chemical Toilets Stored <br /> 3.' ❑ PERCOLATION TEST ". <br /> RiS.or R.C.E. Name R.S.or R.C.E.No. - :Test ation _ A ....� A Test Date/Time - <br /> 4: 6 ANITATION PERMIT lip r. � 3 1 <br /> Job Address/LoCation v102 Is LNwSY �� — AG - <br /> O.��w��ner f�A:t1A_-- S!>st17f1, 'Addtess <br /> Owner <br /> IC TANK ❑ CESSPOOL = W-EACHING FrELO ❑ SEEPAGE PIT ❑ PACKAGE PLANT Q <br /> T '❑ PERMANENT ❑ TEMPORARY :❑'NEW, 7i ❑ REPAIR '❑ OTHER - t <br /> 5' ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction_- "•• 1 -1 • 'Disposal Site <br /> No of Units ' Equ�ment•Stoeage/Cleaning Location(s) <br /> g: ❑ PACKAGE TREATMENT PLANT FopJuly 1.,"June 30: 19 r <br /> -: <br /> Operator Name. Where Certified <br /> - � � � F=- t \ <br /> Plant Location <br /> Plant Capacity t__ r 'r = _ No.units'Served { <br /> 7: 13 LAUNDRY For July 1.-June 30, 19 -t-- <br /> SIZE. ❑ Less Than 1.000 Sq.Ft... ❑ More Titan 1,000 Sq. F�!� <br /> A DRY CLEANING,Chemicals UsaWAmoLnt/W. �.y,� <br /> - .� -will-be� . accordance+ ;th San Joaquin County 1 <br /> Q• <br /> �: 1 hereby certify that I have prepared this-application and that the work done in <br /> ordinances,state laws,and rules and r ulati -otlhe San Joaquin Local Health District. 1 <br /> iAPPLICANT'S SIGNATURE X <br /> �Y 1 <br /> l FOR DEPARTMENT USE ONLY <br /> Fee le DUO:[3 ANNUALLY <br /> fl PER UNIT ❑ PER SITE ❑EACH - ❑ Jaa..aryasneceww By Janu�3' ❑Jvly t a ReCmve-By July-31 <br /> – REMIT <br /> BASE u I EXPLANATION BOATED REMITTANCE <br /> 1 AMOUNT DUE CHECKED--- <br /> ITTED 1 AMOUNTc <br /> FEE — - <br /> - _ r <br /> LESS <br /> PRORATION <br /> 1 PLUS <br /> � PENALTY 1 _ --- .ti - __ � I � '•a.•+ .•. 1 <br /> OTHER <br /> OTHF_R <br /> Col- <br /> r - <br /> Ivo-by _ Data �• _ caapi No. Permit No. M y m _�,� e0 <br /> rWl•IIONMENTAL PERMIT/SERVICE6 '-'^t0o1 E.N <br /> LIMELTON AVE.•P.O.60. 'aTOCKTON,CA 0=1HEALTH <br /> APPCANT•�RETURN ALL COPIES TO:,iP,, .I <br />