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..��.. .. .. ..... —_. .___-__� .... .... ........ . . r_..r .....�._..... .._ .. .� ......,.. .......rte..-.......... <br /> APPLICATION <br /> vas,,r Non-Transferable, Revocable,and Suspendabl <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> ApplicatiC hereby mpde to caj(Y on business in th jurisdictional area of the S Joaquin ocal Health Di trlct <br /> „rt Business Narr (DBA) `�R6r('t� (ick H� � Address 750 <br /> iowner /1 M CAR6f/e 9;2_%- <br /> FirmAddress $y <br /> �. Partners, Addresses and Telephone Numbers <br /> iBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. y39/9 <br /> Applicants Name (Print) - 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.Ll.=,se Renewal No. <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. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E.No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMI <br /> Job Address/Location �yo M055014/e Ro <br /> Owner CV I Nen'l-m Address <br /> ED SEPTIC TANK 11CESSPOOL {L LEACHING FIELD ❑ SEEPAGE PIT - ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site_14600 " $4409tc <br /> No. of Units Equipment Storage/Cleaning Location(s) 11/1L15 '4/7GE 3u <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 /> T. ❑ 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 application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, les and regulations of the An Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X g^� <br /> �a o <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 a Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE _DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE O <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> X133 -a- <br /> Reeeived by IDet Receipt No, Permit No. Iasuan Date MeileO Delivered <br /> APPLICANT—RETURN ALL COPIES TO, ENVIRONMENTAL HEALTH PERMIT/SEWCE3 1601 E.HAZELT YE..P.O.Boa 2009 STOCKTON,CA 0201 <br />