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40, - <br />-App• lications Will Be Processed When Submitted .Properly Completed. Be sure i o*ign <br />APPLICATION <br />(For Non-Transferable, Revocable, and Suspendable) <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />Application i hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health Distric /79e ,-, . Address <br />Address <br />SEPTAGE <br />Business Name (D ) <br />Owner a <br />7, Firm Partners, Addresses and Telephone Numbers I 9 <br />2: Business Telephone No.-99S-Z, 4-7h ..1- <br />Contractor Licence No. _ '2_. 2._. rg <br />Title f•-"r" <br />94 <br />t <I AppliCant% Name (Print) L) <br />Please check Applicable Category (1-7) and Fill in the Required Information <br />1. 0 PUMPER viiiicLe PERMIT REGISTRATION (FOR EACH VEHICLE) , <br />For 431:11y 1 . -1-j--' -June 30, 19 Disposal Sites <br />tlt <br /> CAL. License No. <br />-4 <br />GZ <br />0 1 <br /> Emergency Telephone No. <br />rd <br />Date <br />DescriptionPlakia/Yrs.',I.Color) • • <br />Caaoiy-- -4‘ <br />Equipment Parking Address , <br />Weights & Measures No <br />CAL, License Renewal No. <br />..c <br />2. 0 PUMPER YARD <br />For July 1, June 30, 19 <br />No. of Vehicles.Stored so-a 9- <br />No. of Chemical Toilets Stored <br />0 PERCOLATION TEST <br />R.S. or R.C.E. Name <br />Test .ocation <br />Ell SANITATION PERMIT <br />Job Address/Loc <br />Owner <br />riKEPTIC TANK 0 CE POOL <br />O PERMANENT 0 TEMPORARY <br />0 CHEMICAL TOILETS For July <br />Type Construction <br />No. of Units <br />6. 0 PACKAGE TREATMENT <br />Operator Name <br />R.S. or R.C.E. No. <br />Test Date/Time <br />14' <br />;ddress -Le 5 <br />LEACHING FIELD 0 SEEPAGE PIT 0 <br />El NEW 17;co( 41.11-EPAIR 0 <br />1, - June 30, 19 1 <br /> Equipm ent Sto rage/C I pan mg Location(s) <br />PLANT For Ju ly 1, lIuniti 30, :791' <br />4 1.1 <br />4 <br />f .J <br />,.- ..44. <br />PACKAGE PLANT <br />OTHER <br />„ -- Where Certified <br /> <br />Plant Location . <br />Plant Capacity ____ <br /> (clo. Units Served <br />7,0 LAUNDRY For July 1, - June 30, 19 ..%%ji. -1./ I I I <br />0 DRY CLEANING, Chemicals Used/Amount/MO <br />A SIZE: 0 Less Than 1,000 Sq. Ft., 0 More Than 1,000 Sq. Ft. <br /> ________ 4 <br />I hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin County <br />ordinances, state laws, and rules a egulations of th n Joaquin Local Health District. <br />APPLICANT'S SIGNATURE X <br />EXPLANATION <br />0 January 1 & Received By January 31 <br />REMITTED <br />,,re Fee Is Due: 0 ANNUALLY <br />BASE <br />FEE <br />FOR DEPARTMENT USE ONLY <br />BILLING <br /> REMITTANCE <br />DATE <br /> DATE <br />0 July I & Received By July 31 <br />REMIT <br />AMOUNTAMOUNT DUE . CHECKED <br />AMOUNT <br />44,5 <br />0 PER UNIT 0 PER SITE 0 EACH <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />1W1F t <br />1 - <br />Received by Date <br /> APPLICANT—RETURN AU. COPIES TO: ..• <br />OS6) _50 0 <br /> <br />las ance Oat Mailed Delivered <br />STOCKTON, CA 95201 <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />Receipt No. Permit No. <br />1901 E. HAZELTON T.O. Box 2009