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!-;. { <br /> Applications Will Be Processed When SubAPPLICATIONpleted. Bee Sure " <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE I <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to arry on business in the jurisdictional area of thean Joa u Local Health District <br /> Z h Address <br /> w Business Name (DBA) Address �$y� <br /> aOwner FtV" <br /> j Firm Partners, Addresses and TelephoneAter, <br /> Emergency Telephone No. <br /> CL <br /> Business Tel <br /> No. rZee I _�— L <br /> _J Contractor Licence No. Title ��-- Date r ' <br /> a Applicants Name-(P.,rint)- <br /> L , —$ ' l i 7 and Fill in the Required Intorrnaiion <br /> Please check Applicable•CW ory ( - ) <br /> 1. ATION (FOR EACH VEHICLE) <br /> ❑1 PU144PER`VEHICLE.PERMIT REGISTR <br /> For July 1,-.. ; .-,_ <br /> _June 30, 19 Disposal Sites <br /> description(Make/Yx., Color)_ CAL. License No. CAL. License Renewal No. <br /> :, <br /> Serial`IVo- •- - � # <br /> Capacity = Gal.,Weights &Measures No. <br /> f <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 Stored <br /> k 3. ❑ PERCOLATION TEST R.S.or R.C.E. No. <br /> R.S. or R.C.E. Name . Test gate/Time <br /> Test Location r,^` a � <br /> 4, W SANITATION PERMIT . <br /> 2 Z <br /> e <br /> ! I�� Mrd <br /> Job Address/Location t Address <br /> Owner ❑ LEACHWG FIELD SEEPAGE PIT 13 PACKAGE PLANT <br /> E3 SEPTIC T NK 1:1 CESSPOOL ( {EpAIR 11 OTHER <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW <br /> 5• ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Disposal Site <br /> E Type Construction <br /> Equipment Storage/Cleaning Location(s) <br /> No. of Units �:� <br /> g. ❑ PACKAGE TREATMENT PLANT For July , -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location t — r <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: r ❑ Less Than 1,000 Sq. Ft., ❑;More Than 1,000 Sq. Ft. 4 <br /> C ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Hcm?^A+�a*c-?ce^5sda_�r:'; �4::rr, st?v ollnevirca C_,. J 4 -7`.[7 P vOl.i, ri0 •:ft tiVl- Q rrnSt: isSU'�, IIn0t9Elpl yary{IBrS�R <br /> r,il"nia•. .� <br /> ISf:Cflti!B iLtJj€Ct iG 1Jrl l;',nP�l S:.'Ulllpv'nSdt10n IaN�`o� 1"i 1 shall <br /> Ce�trattn t 5i-iltig o3 5UI;Cnrix +'1: ';9 lit a'ture cer7efieS tkie Sot:n n+ing: "l certify that in the perforinancc of the work for <br /> which',h Is issued.. <br /> l eniploy porsorls subject to r ;c lis CU eilsation fan s at:Califonlia.' 3 <br /> ,�,� ` ,e* <br /> I hereby certify that-h'have prepared this-aPolnsaof the San Joaquin work <br /> al wiHeaeth District.—done in ccordance with-San Joaquin County <br /> ordinances, state laws_ d rules an reg 1 <br /> APPLICANT'S SIGNATURE X_" <br /> I FOR DEPARTMENT USE ONLY <br /> `� PER UNIT ❑ PER SITE EACH ❑ January 1 &Received By January 31 ❑ July ti &ReceiveREllBy July 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ <br /> Y _ 3 BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> REMITTED AMOUNT <br /> •BASE''�"" EXPLANATION DATE DATE <br /> 00 <br /> FEE <br /> I LESS }: <br /> _b <br /> PRORATkON Q <br /> PLUS <br /> PENALTY <br /> OTHER - <br /> I <br /> OTHER <br /> 14 Y <br /> � Permit Nv. ssua ce ate Mailed Delive d <br /> Date Receipt No. <br /> Received by� ;�- {�- 7607&HA2ELTON AVE.,P.O.Boa 2009 � STOCKTON,C 95207 <br /> i, APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> r <br />