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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 /> I:. LIQUID WASTE <br /> Application is h reby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> m Business Nam (D . ) Address .7. -V-CJ <br /> aOwner I��, Address <br /> Firm Partners, Addresses and Telephone Nu bers <br /> aBusiness Telephone No7-ZC7 Emergency Telephone No. <br /> Contractor Licence No. l 7.1 <br /> LApplicants Name (Print) '� C Title C�ri� Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information CCRPtCl" r Baa <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) S SEPTIC & ;,TR SERVICQ <br /> L <br /> 263 So. Oro 41 Stocktor, C31J. 9 205 6` <br /> For July 1, - June 30, 19:1' Disposal Sites <br /> Description(Make/Yr., Calor) IINI Ph. n�-3_ ontractor's Lic. #267177 C <br /> Serial No. CAL. License No. CAL. License Renewal No, <br /> Capacity Gal., Weights R Measures No. <br /> I Equipment Parking Address �M <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 >� <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> t 3. ❑ PERCOLATION TEST <br /> II <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> i 4. O(SANITATION PERMIT 'Ir <br /> f Job Addre ovation / .1 <br /> Owner � I�: Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL EACHING FIELD ,SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 11 TEMPORARY ❑ NEW_ - REPAIR ❑ OTHER G) <br /> 5. ❑ CHEMICAL TOILETS F61r` July 1, -June 30, 19 ar 1S <br /> Type Construction �P Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) ^!' ` <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name I�f.. Where Certified (� <br /> Plant Location q�qL <br /> Plant Capacity J� No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sgl, Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/M0. <br /> I , <br /> I hereby certify that I! have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws;'a rule and regulationVofth San Joaqu' Local Health District. <br /> I 'h <br /> APPLICANT'S SIGNATURE X li CrAHEPXE'S SEPTIC & S[1fl7R KWIC& <br /> 263 So. Ora -t, Stockton, Calif. 9520+ <br /> 1 _ <br /> roc ars _Ic. , 717 <br /> FOR DEPARTMENT USE ONLY <br /> I Fee Is Due: 11 ANNUALLY 1 i ElPER UNIT ❑ PER SITE 11EACH ElJanuary 1 8 Received B J ary 31,Wwn July 1 &Received By July 31 <br /> t BILLING REMITTANCE Imo✓ /] i REMIT <br /> BASE' EXPLANATION DATE DATE ITT �/ AM UNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS I� S chi Ivl <br /> PRORATIONPLUS �tJ� d <br /> PENALTY r ' / `� r/l <br /> ed <br /> OTHER SII d+rj �✓ <br /> OTHERrR <br /> ,:r Q <br /> I <br /> k Received by O to Receipt No. Permit No, Is ante D Mailed Delivered -" <br /> ,i. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELT .,P.O.0—2009 STOCKTON,CA 95201 (^ <br />