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C- <br />-•) <br />SEPTAGE <br />I FJ~2Z>/ <br />Emergency Telephone No. <br />A-Title <br />CAL. License Renewal No. <br />4. <br />Where Certified <br />____No. Units Served <br />APPLICANT’S SIGNATURE X <br /> PER UNIT <br />BASE EXPLANATION <br />AMOUNT DUE <br />CM-FEE <br />OTHER <br />OTHER <br />I <br />Received by Date <br />- APPLICANT-RETURN ALL COPIES TO: <br />-- -----------CAL. License No. <br />Gal., Weights & Measures No. <br />BILLING <br />DATE <br />Delivered <br />STOCKTON, CA 95201 <br />r <br /> <br /> CESSPOOL <br /> TEMPORARY NEW <br />For July 1, - June 30, 19 <br />Disposal Site <br />Equipment Storage/Cleaning Location(s) <br />For July 1, - June 30, 19 <br />03 <br />-O PACKAGE PLANT <br /> OTHER <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />D January 1 <br />REMITTANCI <br />DATE <br /> July 1 & Received By July 31 <br />REMIT <br />CHECKED <br />AMOUNT <br />Fee Is Due: annually <br />Date <br />....... -M , .vpeny V'Uiiip.taeu. ue Uuie iu biyn me Application <br />APPLICATION <br />■or Non-Transferable, Revocable, and Suspeno^ <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />Apphcation^s^eby^to carry on Igsiness iMJie jurisdictionalarea of th^gn^aquin Local Health District <br />/- Address I— <br /> ----------------------------------------------------Address <br />---JeifPhone Numbers <br /> <br />-------- <br />Business Name (DBA) <br />z Owner <br />3 Firm Partners, Addresses and Teli <br />| Business Telephone No <br />J Contractor Licence No. ' <br />* Applicants Name (Print) Q /t-i gj I 0 <br />Please check Applicable Category (1-7) and Fill in the Required Information <br />1. U PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1--------------June 30, 19---------------- Disposal Sites <br />Description (Make/Yr., Color) <br />Serial No.________________ <br />Capacity <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 />3. PERCOLATION TEST <br />R.S. or R.C.E. Name _____________ R - R p_ ------------------------------ ----------------------------- n.o. or H.U.c. NO. <br />Test Location _______________ T t 4VI ------------------------------------------------ Test Date/Time _ PQ SANITATION PERMIT n <br />Job AddreisA.ocation <br />Owner Address <br />^-SEPTIC TANK □ CESSPOOL T^LEACHING FIELD 0fsEEPAGE PIT <br />^PERMANENT TEMPORARY NEW repair <br />*5. □ CHEMICAL TOILETS ' <br />Type Construction . <br />No. of Units _ ____ <br />6. PACKAGE TREATMENT PLANT <br />Operator Name <br />Plant Location <br />Plant Capacity _____________ <br />7. LAUNDRY For July 1, - June 30, 19 <br />SIZE: D Less Than 1,000 Sq. Ft., D More Than 1,000 Sq. Ft. <br />O DRY CLEANING, Chemicals Used/Amount/Mo. <br />nrdZby Cer?y. ,^at ' haVe prepared this application and that the work will be done in accordance with San Joaquin Countv <br />ordinances, state laws, an^^esjind^^ations^the ^n^oaquin Local Health District. A V <br />FOR DEPARTMENT USE ONLY <br />■P PER S,TE □ EACH O January 1 8. Beceive^&y. January 31 <br />_L_______\ <br />ReCeip,N°- Perm,1 No. islukebat^^MSited-- <br />ENV1RONMENTAL HEALTH PERMIT/SERVICES 1S01 E. HAZELTON AVE., P.O. Bom 2009