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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For(For Non-Transferable, Revocable, and Suspendable) SEPTAGE C <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ,Business Name (DBA) WONG+ E,NCHINEEKS LIC Address IIA N• b1UNTE(Z. 1 Sror-r-T'ON <br /> Q Owner C. C"Olkil Woll Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 464_ —4✓aS"z- Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) C. CWilm N1 oW Cs� Title PEES Date <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 i, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER.YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Store <br /> 3. %.PERCOLATION TEST <br /> R.S. C.E. Name C A NCE Wools-. R.S.or R.C.E. No. �••C. t¢'2..�9 <br /> Tes1FOREST LhKE F • LDWEIZ TestDate/Time <br /> 4. SANITATION PERMIT ShC -4\1K Wr0 <br /> Job Address/Location Cu-.�-I' a^' `' UNL'�' NOS Z- <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/AmounVMo. <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 and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 a Received By July 31 <br /> BILLING REMITTANCE $ REMIT AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> B <br /> AMOUNT <br /> FEE 7 --gas V <br /> LESS G O <br /> PRORATIONAl <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 36 O�S� CA -- <br /> Received at Receipt No. Permit No. las soca to Mailetl Delivered <br /> APPLIC NT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.S.2009 STOCKTON,CA 95201 <br />