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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTneAppncanon. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,'and Suspe idable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT'" <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the SaJoaquin Local�Health District," 7 A <br /> r A. <br /> Business Name (DBA) 101 All '4 '��'�� Address. <br /> Address <br /> a Owner _ <br /> J Firm Partners, Addresses and Telephone Numbers ` <br /> 11!!!!!i1. 101 b Emergency Telephone No. <br /> aBusiness Telephone No. f <br /> Contractor Licence No. <br /> / " Title DateogjC �� <br /> Applicants Name (Print) 5 <br /> Please check Applicable Category (1-7) and Fill:in the Required Infor anon y <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. El PUMPER YARD �k <br /> For July 1, .June 30, 19 - --.> <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored , <br /> 3. ❑ PERCOLATION TEST + t <br /> ,.; ..;�.....:. R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name r <br /> Test Location Test Date/Time <br /> 4. 'M SANITAThON PERMIT ~ <br /> Job Addres Locat on �J y ` <br /> Owner 'ICY �"ru;3"`�~ Address ❑ PACKAGE PLANT " <br /> ❑ SEPTIC TANK ❑'CESSPOOL LEACHING FIELD GE PIT <br /> 13 PERMANENT ❑ TEMPORARY '"❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS?tFfor July 1, June 30, 19 <br /> ; ' <br /> Type Construction i Disposal Site_ <br /> No. of Units *-Equipment Storage/Cleaning-�Location(s) <br /> 6. .13 PACKAGE TREATMENT PLANT- For July 1, June 30, 19 t I Where Certified <br /> Operator Name - ~ <br /> k <br /> Plant Location <br /> Plant Capacity _ No. Units Served . <br /> 7. ❑ LAUNDRY For'July 17 June-30,~19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., "`"❑ More Than 1.,000S4. Ft. i <br /> - ❑ ORl � hemicals Used/Amount/Mo.,, <br /> S4,001F@.11000gP! @Fr9fl ft!rpq�+HttiPeftft3l"Winly1reirI#yt�allflthn.pCr(q{mance 4lfhoWorkfprtithlEklibisprrmifisiSSued,lshaltnotempioyanyperson <br /> !fl?3@l sa{Pref @5 Efa B�il� su1314@i(+l+4a{knlatl'S cpsilire{l�alt4�laws plea€iforni�. c � <br /> 9r'1T�E4sr'>; 04-14 ns �(a-Utanr+aptigg sie,skatkrxe certifies lI,, fQlt = <br /> (3fi1 IBli jl@f138€+3 X1490 iQ W@�l(il4 fl°?6g[]1�eil5alie[1 IDWS 01Q10ofnia, cwiae' ''1 Cattily that in the per#orrianee of lila work for which this permit is issued,1 shall <br /> ;t- y1 „ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance-with San}Joaquin County <br /> + Loc I Health District. .on <br /> ordinances, state laws, and es and regulations of the San Joa <br /> APPLICANT'S SIGNATUREX�� <br /> FOR DEPARTMENT USE ONLY ! <br /> 'Fee is Due: ❑ ANNUALLY �' ❑ PER UNIT REMIT <br /> SITE ❑ EACH ❑ January 1 &Received By January 31 E] July 1 &ReceivedJuly 31 <br /> REMIT <br /> { BILLING REMITTANCES; $ CHEC':BASE EXPLANATION - DATE- .j-..DATE,--..aP. �=REMITTED..-.krAMOUNTOUE <br /> � "� ��*- AMOUNT <br /> FEE 4 45 ej 3 <br /> LESS 7 s 1. •fps. - . <br /> PRORATION" <br /> PLUS - - <br /> I PENALTY <br /> OTHER <br /> OTHER _ #:• - <br /> w a _ <br /> Issuance Gate Mailed Deli red <br /> Received by Date <br /> Receipt No. permit No. ` <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE:;P.O.Box 2009 STOCKTON,CA 95201 <br />