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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 -02- <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) P. A. PAR.P—)SI! 7 SC1 4!Q ,rM )C_ Address Fin Sc4ic 114-510 SM;:JV' cl's <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL <br /> Business Telephone No. �(o -9)4,0`7 _— Emergency Telephone No, <br /> Contractor Licence No. Jam-,_____ t <br /> �Applicants Name (Print)_ T'A' 1t_k=_y 3 . !Sims Title ESX1_MA.TetZ Date 4-30—Si <br /> ---_ <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites `I <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. _ <br /> Capacity Gal.,Weights & Measures No. P <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARDi <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 l R.S.Or R.C.E. No. _ <br /> Test Loc ion Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location i21010. 13 riU 534W i 7-0 A-) 3 <br /> Owner 54'k1)'J(4 (:f.V-t;.!' c�r��-r�.y CL-Q'19 Address 0 <br /> M`<EPTIC TANK '❑ CESSPOOL Gi-CtACHING FIELD ❑ SEEPAGE PIT PACKAGE PLANT <br /> S-0ERMANENT ❑ TEMPORARY 2--NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction 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 Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 74 t <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq.'Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I hereby certify that 1 h prepared thi application d hat the o will be done in accord a 't San Joa in ounty <br /> ordinances, state law les and r ulations of.t Jo in ocal �ealth District. !� <br /> APPLICANT'S SIGNATURE) <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 61LLING REMITTANCE $ REMIT <br /> BASE EXPLANATION PATE DATE REMITTED AMOUNT pUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS Y <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No ssu nce ate ailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES itio1 E.HAZELTON AVE., . .Box 2009 STOCKTON,CA 95201 <br />