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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION 2,-30 <br /> (For Non-Transferable, Revocable,.and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application itsreb made to r n business in the jurisdictional area of th an Joa uln Loca H Ith District <br /> n Business Name (DBA)W- Wal—� bw .• Address; <br /> x Owner Address <br /> U Firm Partners, Addresses and Te one Numbers <br /> 73 <br /> a Business Telephone No. 6` Emergency Telephone No. <br /> 54 <br /> Contractor Licence No. - <br /> a _ taiv q�lt� Dater <br /> Applicants Name (Print) Title _ t <br /> Please check Applicable Category.(1=7) and Fill in the Required Informati n w g o- w <br /> ..,f �, - 1 . .: . a _ - :.i ", • w it <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July-1, .-.- June 30;.19-- - — ...pDisposai:Sites - - - <br /> Description(Make/Yr., Color) <br /> 'Serial No. CAL. License No. CAL. License Renewal No.� <br /> Capacity Gal., Weights &Measures No. t <br /> ) <br /> "Equipment Parking Address <br /> 2. ❑ PUMPER YARD _. .�..,.....P..--.._-.�-,.-•�...T•r....�:..�....��..._....... �.»......-� i-.,:q....".«,.�.w...,-......� , <br /> 1 <br /> For July 1 June 30, 19 — <br /> of <br /> 9 of Vehicles Stored <br /> c <br /> No. of Chemical Toilets Stored s t <br /> 3. ❑ PERCOLATION TEST } <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. a t <br /> j-= Test /dime " <br /> Test Location bate E r f <br /> 4. tel-SANITATION PERMIT <br /> Job Address/L cation ' <br /> Owner ? f Address # ) t ( ` <br /> \11 SEPTIC TANK CESSPOOL. -KLEACHING FIELD ;,SEEPAGE PIT ❑ PACKAGE PLANT <br /> WPERMANENT 1P TEMPORARY 11!NEW ❑ REPAIR ❑ OTHER # <br /> 5:'t ❑ CHEMICACTOILETS For July 1, -June 30,19 .' <br /> Type Construction 5... Disposal Site <br /> No'of Units f Equipment Storage/Cleaning Location(s) <br /> '6. t PACKAGE TREATMENT PLANT For July 1., -June 30, 19 �. <br /> Operator Name j - WherdCertified' <br /> Plant Location <br /> Plant Capacity_ � � """� � � � ' ._ No. Units Serves- <br /> M- 7.r❑ LAUNDRY Fo'r July ,.-.June 30, 1.9,-._. ii- � . <br />« SfZE: L ss Th n 1,00 Sq; Ft., lEl More Than 1,000 5q !Ft. <br /> DRY CLEANING=Chenais Used/Amount/M} o. } R <br /> 1,he reby-certify That I havejp'repared this applicaVoniand that(he work will be done in accordance with San Joaquirl;-Cou�nty <br /> rdinances, state laws, and rules and re ulatio f th San Joaquin Local Health District. ii°°` <br /> o _ <br /> APPLICAAT'S SIGNAT.UREXov <br /> }r Gj),\ � is <br /> C, FOR bEPAR HENT USE ONLY t <br /> Fee Is Due' ❑ ANNUALLY ❑ PER UNIT.. a�0 PER SITE `.jEACH ❑ January 1 &R4 eived By,January 31' - ❑ Ju$y 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> + <br /> FEE J t <br /> LESS <br /> PRORATIONPLUS <br /> �G ' <br /> PENALTY' <br /> i OTHER <br /> - l 0'7 <br /> Received by Date Receipt No. Permit No. Issuan a Da Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZE LTON A .O.Box 2009 = STOCKTON,CA 95201 <br />