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5• q 2 _411 ei APPLICATION _*` 7 "9' " <br /> For Non-Transferable, Revocable, and Suspeno�) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San oaquin Local Health District <br /> F Business Name (DBA) ' A4110,164114 Y'/;�Z� __ Address L'"Z� 1A/ r'L%A ST LWt <br /> i Owner��f`,"�� YlilZ Address�w' M- f+o' %'r L-40 ! Gd . 9 4^;ZA - <br /> Firm Partners, Addresses and Telephone Numbers j --- <br /> aBusiness Telephone No. -���� �� Iii Emergency Telephone No <br /> Contractor Licence No. -- <br /> Applicants Name (Print) n -r,Y F117-%A __ Title Date <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 <br /> Description(Make/Yr., Color) -- <br /> Serial No. - CAL. License No. _CAL.License Renewal 14m - <br /> Capacity ___-- -_ _ _ Gal.,Weights&Measures No -- <br /> Equipment Parking Address - -- <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 - <br /> No. of Vehicles Stored - - <br /> No. of Chemical Toilets Stored - <br /> 3. 09 PERCOLATION TEST <br /> R S or 1 C N�ame `i�_ ""•Y k-17-2A <br /> R.S. o No. <br /> Test Location ` 10 u _1%4 A�1 !LLE rVTest Date/Time - <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location - <br /> Owner _ _ - Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT -❑ PACKAGE PLAN <br /> ❑ PERMANENT ❑ TEMPORARY ❑ 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 _ <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 I have prepared this applicatigirr and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regu San Joaq6in Loyal Health District. <br /> APPLICANT'S SIGNATURE X - -- <br /> 2 Ts- <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t&Received By January 31 ❑ July 1 &Received EMlTBy uly 31- <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE MATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER I <br /> 1- <br /> OTHER <br /> Received by Date Receipt No Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />