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_ APPLICA'FION <br /> (For Non-transferable, Revocable, and Suspendable) M <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is''hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ''ss Name (DBA).p, � _Add res, $�,� .T�p 95 <br /> Address <br /> 'artners, Addresses and Telephone Numbers <br /> ;ss Telephone No. 110_ o Emergency Telephone No. <br /> ctor Licence No. <br /> tants Name (Print) "Tr.1 trnol Title bate 1 �� <br /> check Applicable Category (1-7) and Fill in the Required Information <br /> kPUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> ily 1, June 30, 19 Disposal Sites p <br /> pilon(Make/Yr., Color) /1 <br /> No. CAL. License No. CAL. License Renewal No. a <br /> ItY Gal., Weights& Measures No. 6 <br /> pent Parking Address dQ <br /> PUMPER YARD <br /> IIY 1, June 30, 19 <br /> Vehicles Stored <br /> Chemical Toilets Stored <br /> PERCOLATION TEST � :lA <br /> R.C.E. Name R.S. or R.C.E. No. <br /> ocation <br /> Test Date/Time <br /> SANITATION PERMIT _. <br /> Jdress/Location g I L epDoQ <br /> 5�112SCactflde++`] _ Address J4 V <br /> PTIC TANK ❑ CESSPOOL MILEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> RMANENT ❑ TEMPORARY ❑ NEW b-TIEPAIR ❑ OTHER <br /> CHEMICAL TOILETS For July 1,-June 30, 19 <br />'onstruction Disposal Site <br /> Units Equipment Storage/Cleaning Location(s) <br /> PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> or Name Where Certified <br />.ocation <br /> rapacity No. Units Served <br /> LAUNDRY For July 1, -June 30, 19 <br /> ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> CLEANING, Chemicals Used/Amount/Mo. <br />�� d N f'c�` •r�/� /�,',�o � 1—� /�`M S�d' .lit/ .�. ,� <br /> I hereby certify that I have prepared this application and th t the work will be done in accordant it""an Joaquin County <br /> ordinances, state laws, nd rules and gulations the San oaquin Local Health District. !( <br />;ANT'S SIGNATURE X <br /> 10 <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> ee IS Due: ❑ ANNUALLY ❑ PER UNITt <br /> ❑ PER SITE ❑-EACH E114anuar is eceive By January 31 ❑ July 1 &Received By July 31 <br /> J <br /> BASE EXPLANATION BILLING REMIT $ REMIT <br /> DATE DA REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> EE <br /> ESS <br /> RORATION <br /> LUS" <br /> ENALTY <br /> THER <br /> THEA <br /> eceived n Z b Y +Or✓ <br /> Y Date Receipt No. Permi[No. Issuance a Mailed Delivered <br /> APPLICANT—RETURN ACL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON .O.Box 2009 STOCKTON,CA 95201 <br />