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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 <br /> O Business Name (DBA) • t"APP_i5P 15D )S; :a.r,JC - Address i P —SI-rK ' ��c <br /> aOwner 1 Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> ILBusiness Telephone No. Emergency Telephone No: <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title QST( f`t �� I- Date ) <br /> Please check Applicable Category (1-7)and Fill In the Required Information _ PA <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) „f <br /> For July 1, June 30, 19 Disposal Sites _ ! <br /> Description(Make/Yr., Color) <br /> Serial No. {; —- t ! . CAL. License No. CAL. License Renewal No. l <br /> Capacity f GaI.,,.Weights &,Measures No:" <br /> Equipment Packing Address f (- i" # <br /> 2. ❑ PUMPER YARDe <br /> For July 1, iJune'30, 19 T• t <br /> No. of Vehicles-Stored <br /> No. of Chemical Toilets Stored -- –•--- <br /> 3.- ❑7PERCOL-ATION TEST.. <br /> R.S. or R.C.E. Name :f R.S. or R.C.E. No. <br /> Test Location e. `` Test Date/Time <br /> SANITATION PERMIT { <br /> 4. ❑ jj <br /> )I ISC,A) �� _ `7 I �G 7J <br /> Job.Address/Location � 5 <br /> Owner ,L:1r,jv c 1A tZ7L ' Address 1S,3 IVYDiL- <br /> ❑'SEPTIC TANK' `CESSPOOL 2LEACHING FIELD R-SEEPAGE PIT ❑ PACKAGE PLANT <br /> fl PERMANENT O TEMPORARY ❑ NEW ,❑ OTHER <br /> 5. ❑­CHEMICALTOILETS. For July 1,-June 30, 19 <br /> e{Construction Disposal Site <br /> zte R <br /> No of Units 4 4J +Equipment Storage/Cleaning Location(s) <br /> 6:5.,D.PACKAGE-TR EATMENT'PLANT" For July 1, -June 30 ;19—p "- <br /> fOperator.Name'' "'-�-�-T " "t-�`•• { ' Where Certified � <br /> Plant Locatldr5: • - F r-+ �t € . h ; r \ <br /> Plant Capacity I "' '• s ; No. Units Served f <br /> 7. 'CI LAUNDRY For July 1, -June 30, 19 <br /> 1 <br /> ` SIZE: Less Mian 1,0 <br /> ❑ 40 5q. Ft. ❑'More Than 1,000 Sq. Ft. ) <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. # r <br /> f <br /> I herebytcertify that I ha a prepared this application and that'the work will be done in accordance with San Joaquin County <br /> f ordinances, state laws, d-rules 4nnd regulaticis of 1 'e Sa'n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> G <br /> c ` <br /> F <br /> _J 4 FOR DEPARTMENT USE ONLY <br /> Fee Is Due]-[] ANNUALLY = ❑ PER UNIT ❑ PER SITE 1.01 E CH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> . F <br /> BAREMITS <br /> SE EXPLANATION BILLIN REMIT E $ AMOUNT DUE CHECKED <br /> r,..... - ••• - � i DAT DATE REMITTED_ AMOUNT ' <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER I ? fIlkr x <br /> OTHER ; <br /> 4 " <br /> Received by Date is R4deipt No t t Jy,_Verm1t:No. �,.� _)ICsbarWe bale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.eox 2009 STOCKTON,CA 95201 ` A <br />