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Applications Will Be Processed When Submitted Property Completed.Be Sure To Sign The Application. <br /> 4PPLjPATI ON ,F <br /> (For Non-Trsnslerable,Revocable, and Suspendable) ^`- <br /> �INENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> �� LIQUID WASTE <br /> Application <br /> niis rebymadeto Carry on business in the jurisdictional.area of thRU�en J,S�gwn,Local Health�Jstrict <br /> prosiness Name(DBA)ar— OLtGi� �7 1S TLt! - Address ! D - .�t'9[ 1�$a .-ZT7�.LJ <br /> Owner I I Address I <br /> zu Firm Partners, Addresses and Telephone Numbers f <br /> S Business No.Telephone o I <br /> p C�l��r>�`� Emergency Telephone No. <br /> Contractor Licence No. 2.54� —343 <br /> Applicants Name (Print) ✓1�„ rM� �EAa S Titil aY - Distill <br /> PW11e check Applicable Ca: (1-7)a1 InBIe Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1.—__—June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. _CAL. License No. CAL.License Renewal No. <br /> Capacity Gal., Weights& Measures No. <br /> Equipment Parking Address _ y--/ <br /> 2. ❑ PUMPER YARD <br /> For July I. June 30, 19 I <br /> No.of Vehicles Stored e� <br /> No. of Chemical Toilets Stored L� <br /> r 3. ❑ PERCOLATION TESTI ` <br /> R.S. or R.C.E. Name R.S.or R.C.E.No. <br /> Test Location = I;1 Test Date/Time p <br /> e. E SANITATION PERMIT��A"vie & r(jrT O} O -/�Z 3� ({{ <br /> Job Addre /Location W 1 <br /> O�w�r oA.siQ' AnnrRss <br /> IQS_WTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT , <br /> L"ERMANENT ❑ TEMPORARY 0-11EW ❑ REPAIR ❑ OTHER ) <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 i <br /> pe Construction t Disposal Site P <br /> '%Ko- of Unita Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For duly 1,-June 30. 19 _ <br /> Operator Name --. - - - Wham CotiRlad - <br /> Plant Location <br /> Plant Capacity - ' No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 - r <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1.000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/MO. <br /> I hereby Malty that 1 h e prepared t is appiica' an at the work will be done in accordance With San Joaquin County <br /> ordinances, state lows rules an Ulatio the Joaqu Local Health District. <br /> APPLICANTS SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑PER UNIT E] PER SITE ❑ FACH- ❑ Jenunry 1 a Reael.9e BY J11rtwry 31 ❑July 1 a Recei.ea by July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS1 <br /> PRORATION <br /> , <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER i • . <br /> t>Y Date »Racaipt N. Permit No. lenience D1119 1190 Y iyelW <br /> `. A aIF,��PAL,`f'�OPIEa TO. ENVIRONMENTAL HEALTH PERMITISERVICES taH a NASILTON AVE..P.O,S.20011 STOCKTON - <br /> t� vim. I <br />