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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 ;i 6 <br /> F Address <br /> Business Name (DBA) <br /> P 0 Box' 1 84 <br /> Ga _95536. <br /> a Owner dwaT'C� Address++ <br /> L <br /> J Firm Partners, Addresses and Telephone Numbers E223 <br /> I <br /> CL Business 7ekephone No. � Emergency Telephone No.—823-2-4;)3 <br /> r <br /> Contractor Licence No. <br /> Applicants Name (Print) Rid-ward E. Pi -tis Title � tWE'T' Date <br /> pp <br /> I Pleasecheck Applicable Category (1-7)and Fill in the Required Information <br /> 1 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites y <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights &Measures No. r <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 j <br /> No. of Vehicles Stored �I <br /> No. of Chemical Toilets Stored l r <br /> 3. 11PERCOLATION TEST " I! <br /> I <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location ► Test Date/Time <br /> 4. 12.SANITATION PERMIT <br /> Job Address/Locati n A- <br /> r Address— <br /> TIC <br /> Owner ❑ PACKAGE PLANT " <br /> IX SEPTICe <br /> K ❑ CESS OL " LEACHING FIELD ❑ SEEPAGE PIT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR C OTHER <br /> 4( 5. 11 CHEMICAL TOILETS For July 1, -June 30, 19 <br /> � ► f ! O �� <br /> f Type Construction Disposal Site <br /> No. of Units — Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 G <br /> Where Certified <br /> Operator Name <br /> Plant Location a <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 y <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. L <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> C <br /> I hereby certify that I have prepared this a plica ion and t ork will be done'in accordance with San Joaquin County f <br /> ordinances, state la s and re ons th ealth District. <br /> APPLICANT'S SIGNATURE <br /> Manteca lambing Company <br /> " FOR DEPARTMENT USE ONLY <br /> I <br /> Fee IS DUB: ❑ ANNUALLY PER UNIT- PER SITE ❑ 'EACH ❑=January—1 &-Received By January 31 C] July 1 8 Received 31 <br /> BASE EXPLANATION BILLING, .-"d.REMITTANCE TAMO7UNTDUET:AMOUNT <br /> HEGKED <br /> DATE DATE REMITTED Lq <br /> FEE L r <br /> -Jy 3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 1 <br /> OTHER <br /> 7 � <br /> ti Iss ante Date ai ed Delivered; <br /> Received by Date Receipt No Permit No. „ <br /> I <br /> APPLICANT—RETURN ALL COPIES to: ENVIRONMENTAL HEALTH PERMIT/SERVICES 4641 E.HAZELTON AVE.,P.O.Box 2099 STOCKTON,CA .{ <br />