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Applications Will Be Processed When Submitted Properly Completed. BeSureTosign Inesappucauvn. <br /> APPLICATION <br /> (For Nan-Transterable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereb made to carry n business in �lsd`ictional area of t San Joaquin Local Health District�" <br /> T1 A �t°AAL1 �-A- c •...Address �_ �k t4�� <br /> F Business Name (DBA) <br /> Address <br /> za Owner y <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. 444_—% Emergency Telephone No., <br /> Contractor Licence No. I <br /> 1 Title" Date <br /> L Applicants Name(Print) A <br /> Please check Applicable Category (1'-7) and Ill in the Required Information.- <br /> 1. 13PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, -June 30-19 } - Disposal Sites u <br /> Description(Make/Yr., Color) ( l <br /> CALicense No-. CAL. License <br /> L- Renewal No. r . <br /> Serial No, c A A <br /> "Capacity - Gal.,Weights &Measures No. r <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1 June 30, 19 — <br /> No. <br /> 9 No- of Vehicles Stored <br /> No. of_Chemical Toilets,Stored <br /> 3. ❑ PERCOLATION,TEST , 1 C,6, <br /> ,: R.S. or R.C.E. No- <br /> -R.S. or R.C.E. Name <br /> Test Location; Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner 7'1?i L.E ' HING ❑ <br /> Address ^ <br /> 13 SEPTIC TANK ❑ CESSPOOL. " l'❑ 'EACFIELD C}"� EPAGE PIT PACKAGE PLANT ro <br /> ❑tREPAIR �C3THER -- A-9—EJ S <br /> A �' 1A I <br /> ❑ PERMANENT E] TEMPORARY ❑%1VEW <br /> 5. 11-CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction ' - Disposal Site _ <br /> E uirment Storage/Cleaning Location(-§) <br /> No.-of-Units q P _... f <br /> g. ❑,PACKAGE TREATMENT PLANT For{July 1,-June 30.19 a <br /> *1 - Where Certified <br /> Operator Name <br />' Plant Location <br />' Plant Capacity I 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 /> I ❑ DRY CLEANING, Chemicals Used/Amount/Mo.- " <br /> I hereby certify that I e repay this Iication_a at thew wi{I be done in accordance with San Joaquin County <br /> tions of th Joaq oc Health District. <br /> ordinances, state laws, n g r <br /> te <br /> APPLICANT'S SIGNATURE X , <br /> /fi FOR DEPARTMENT USE ONLY-_14 <br /> Fee IS Dile- [1 ANNUALLY J ❑ PER UNIT j❑ PERSITE13 EACH ❑ January_l &^Received By January 31 July 1 &-ReceiveRdEMITBy 11 uly 31 <br /> I t ;BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE - 'DATE "REMITTED AMOUNT <br /> O % <br /> FEE ✓ <br /> I <br /> LESS - <br /> PRORATION - <br /> PLUS <br /> PENALTY f r <br /> n OTHER_A_n �.. _. .. - - �— I7'- <br /> OTHER <br /> "� <br /> Received by ' <br /> Date Receipt No- Permit No Issuance Date Mailed Delivered <br /> 1601 E.HAZELTON AVE,,P.O.Box 2a09 STOCKTON,CA 95201 <br /> �- APPLICANT—RETURN ALL COPIES TO: <br /> "ENVIRONMENTAL HEALTH PERMIT/SERVICES _ �� <br />