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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 Distrlc <br /> rn Business Name (DBA) RA P_ S MMC- AddressQC�X 114C6 <br /> aOwner .-Address <br /> Firm Partners, Addresses and Telephone Numbers A. <br /> v <br /> CL <br /> Business Telephone No. ��"� �� F - , Emergency Telephone No. <br /> Contractor Licence No. T s <br /> Applicants Name (Print) Title Date '�2 <br /> Please check Applicable Category.(i-7) and Fill In the Required Information <br /> 1. ❑ PUMPER VEH_ICLE_PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, F June 30';19 = "Disposal Sites--- <br /> Description(Make/Yr., Color) t ry <br /> Serial No. CAL. License No. CAL. License Renewal No. Y <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address I <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 i : No. ; <br /> R.S. or R"C.E <br /> Te t ovation f+ ' t ;t n = Test,Date/Time 24 <br /> A. SANITATION PERMIT •-e; y a;„ • ! t t <br /> Job Address/Location QL�l V� <br /> CLUS BLVD. <br /> O C3ner "Address-7-11144 ., T <br /> SREPTIC TANK CESSPOOL. X LEACHING FIELD SEEPAGE:PJTr-�I ❑ PACKAGE PLANT <br /> 3K PERMANENT ❑ TEMPORARY �NEW,f' # r3 R�PAIRs .,: «�1'-.'e OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June;30,"19 -.-___� t . <br /> Type Construction 1 Disposal Site, �. <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July•1#-)June 30,0.9 <br /> OperataY Name � �- t - Where Certified. , <br /> PtlANYLocPtiorV_ I`' r r_ <br /> Plant Capacity y-V- f!r •°''s,1 No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> �., j <br /> 51ZE:� ' l:es'Than;1i000.Sq`: ft; 0 More Than 1,900 Sq. Ft. l <br /> ❑ Y,.�bP�li��'�leou IiAo <br /> 0:such mamRerastobecornssultjeats;rellnttatf�s tr iwlenrlM ,7 ttiafMtM lle+lrrlktor *lhlhi fter tislasued.lsAiaffnot employ arryperscn . - <br /> f Of i <br /> Contractor's Md" or sub eontretttrt 4kyVjWjLft 4ettlt4e R*work for which tf�f5 petmii is issaed.I shalt <br /> empioy JWSO es sutgei t t6 workMalisyCam�elfsalloftHwl�Ci#fdNtiak" :E.w #t, ; ; I <br /> I hereby certify that I have pared this application and that the work-will be a in ccordance with San Joaquin County <br /> ordinances, state laws, a ul s d regulations he's6n Joa oval He h istrict. <br /> ` <br /> Y f <br /> APPLICANT'S SIGNATURE X <br /> 41 } <br /> #r, FOR DEPARTMENT' LSE ONLY <br /> j r l�' <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT 13 PER SITE ❑ EACH El January 1 &Receive By January 31 ❑ July 1 &Received By July 31 = <br /> REMIT <br /> 91LL4NG RENIITT)4j4t;E� ' <br /> BASE EXPLANATION � .�„ .J "H "ti> €AMOUNT OLi.EC "-'^CHF�C'KED <br /> D'ATE - ..mow DATE. REMITTED. x.. AMOUNT <br /> FEE <br /> LESS ,,, <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER #' -..:+ --4•.•r.:rssre.,.,i w:,.�v - ti h� � �ab*' ..- q_:' u�r'� . <br /> OTHER - <br /> � r �_A <br /> Received by 4. ,� Date ' Receipt.No Permit No, - issu nce De Mailed Delivered <br /> 5 ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL-HEALTH PERMIT/SERVICES "-- 1601 E.HAZELTON .,P.O.Box 2009 STOCKTON,CA 95201 <br />� ^ k <br />