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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ' APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE ' <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) Crutchfield Const, Co. Address 332 N. Patrick Rd. <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 20 6 2 Emergency Telephone No. <br /> Contractor Licence No. 358896 <br /> Applicants Name (Print) Harold Crutchfield Title Treasurer Date 2-o6-8C <br /> Please check Applicable Category (1-7)and Fill in the Required Information i <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites S <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 J <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. w <br /> Test Location Test Date/Time i <br /> 4. ® SANITATION PERMIT <br /> Job Address/Location 31, ,1-6, East Miner Avenue Stockton CA <br /> Owner Auto Rite Dismantling Address 3436 East Miner Stockton CA <br /> ❑ SEPTIC TANK ❑ CESSPOOL ♦1GALEACHING FIELD M SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW I? REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ' <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <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/Amount/Mo. <br /> I hereby certify that I have pre ed this applicatio d that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and regulatio San ;oaggin Local Health District. <br /> APPLICANT'S SI <br /> _ r <br /> FOR DEPARTMENT USE ONLY / <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED J AMOUNT <br /> FEEjGT <br /> LESS <br /> PRORATION <br /> PLUS <br /> - PENALTY J pit, <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit- o. Issuance Date Mailed Delw ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1611 E.HA2ELTON AYE.,P.O.Box 2009 .5T0 TON,CA 101 <br />