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Applications Will Be Processed When Submitted Properly Completed. BeSureToSign TneAppucallOu. <br /> APPLICATION <br /> ;i, (For Non-Transferable,`Re-vReSuspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH;PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> $, <br /> Address <br /> Business Name (DBA) ��� <br /> G. 141114l s7' STt3 ,rJ <br /> r g -Address <br /> QOwner - ,. „- ,-. .�.. -., -.,.. <br /> !6? Firm Partners Addresses and Telephone Numbers <br /> -&j <br /> Business:Telephone No. — `�7�' Emergency TelephoneFNo.0 _ <br /> Contractor Licence No. - - - <br /> Applicants Name,(Print) FI�YD &:1�9d t7 Title Date <br /> ` Please check Applicable Category.,(l-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> � � - _ :"� Disposal Sites <br /> For July is - - June-30; 19� p - <br /> Description(Make/Yr., Color) . <br /> Serial No. '�' `- - r ;„� . CAL. License No. CAL <br /> ..Licensei Renewal No. <br /> Capacity 'Gal.,Weights & Measures No. <br /> Equipment Parking-Address <br /> 2. ❑ PUMPER YARD fY. , . <br /> k For July 1, June 30,-19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> i 3. ❑ PERCOLATION TEST , <br /> R.S.or R.C.E. Name R.S. or R.C.E. No. <br /> .1 <br /> TestsLocation Test Date/Time T <br /> 4. A-SANITATION PERMIT A <br /> 1 1-, , <br /> rJob Address4Location <br /> ( Owner'�'A�1114 C�L� TyPA'SS�' Address -� <br /> r SEI TANK _ ❑ CESSPOOL LEACHING FIELD 19 SEEPAGE PIT ❑ PACKAGE PLANT"` <br /> E PERMANENT ❑ TEMPORARY _ Id NEW 4 ❑ REPAIR 11 OTHER � <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June`30;,191."-t . .11. , i <br /> Type Construction Disposal site - -� <br /> No. of Units Equipment Storage/Cleaning Location(s)" <br /> 6. ❑ PACKAGE TREATMENT PLANT Where Certified-For July 1, -June 30, 19 <br /> 1f <br /> Operator Name $- <br /> Plant Location - <br /> No. Units Served <br /> Plant Capacity ' } <br /> I- 4. ❑ LAUNDRY For July 1, -June 30;19 i <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 13'-More Than 1,000 Sq. Ft. <br /> I ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> hereby certify that I have prepared this application and that'the work will be done in accordance vaith San Joaquin County <br /> ordinances, state laws, and rules and regulations f-th San Joaquin.Local Health District. T M ; <br /> 4 <br /> f <br /> APPLICANT'S SIGNATURE X t e <br /> FOR DEPARTMENT'USE ONLY - <br /> Fee Is Due: ElANNUALLY _ ❑ PER UNIT ElPER SITE. ❑ EACH ❑ January 1 &Received By January 31 El July 1 &Received By July 31 <br /> REMIT <br /> ' BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> REMITTED # <br /> BASE EXPLANATION <br /> ... -.. - DATE � �— .DATE - �� - AMOUNT <br /> F A—Tq . <br /> yx <br /> f <br /> FEE <br /> LESS . <br /> PRORATION <br /> PLUS <br /> PENALTY n <br /> OTHER <br /> OTHER-' - <br /> Received by Date 'Receipt No <br /> Per o. Issuance Date mailed Delivered <br /> 1 APPLICANT—RETURN ALL COPIES TO, 'ENVIRONMENTAL HEALTH PERMIT/SERVICES p� 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />