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APPLICATION <br /> or Non-Transferable,Revocable,and Suspendat SEPTAGE <br /> \r/ ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San J aquin Local Health District <br /> %Business Name (DBA). Lc'cZryuiv✓ Address � �,G�2-` <br /> Owner - Address <br /> Firm Partners, Atldresses and Teleph0 a Numbers _ <br /> 'u Business Telephone No. '1 � ,7 Emergency Telephone No. _ <br /> 1.Contractor Licence No. <br /> Applicants Name (Print) -1. r%�/t=f7_ __ Title dl GtiV 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. Li6ensei36. CAL:License Rehewal W. - <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 -i <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name ` ' R.Syor R.C.E.No. <br /> Test Location Test Date/Time �- <br /> 4. V SANITATION PERMIT <br /> Job Address/Location _ F Tol RD .S �O/Lif <br /> Owner Address - <br /> SEPTIC TANK -❑ C SSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY El NEW 13 REPAIR ❑ OTHER l _ <br /> S. ❑ CHEMICAL TOILETS _r6r-4ulg4.'lune 30, 19 ' <br /> Type Construction - Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) �I <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name ��.-. - Where Certified <br /> Plant Location <br /> Plant Capacity l - 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.'FL <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. - <br /> y i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San'9oaquin County <br /> ordinances,state laws, and rules and. at ns of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY - - <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EAC H ;Q Jangaryl 8 Received ByJanu 731 ❑ July 1 8. eceived By Jul 31 <br /> i REMIT <br /> BILLING 'S REMITTANCE $ <br /> @ASE E% N ,ION a AMOUNTOUE- CHECKED' <br /> r flATf '- 'DATE REN$TTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS t <br /> PENALTY <br /> OTHER <br /> OTHER• ,._ <br /> � 9 - � ` Y <br /> �Reeceive0 by Date Receipt No. Permit No. ilsuanck Date Malted Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 4601 E.HAZELTON AVE.,P.O.Bok se09 STOCKTON,CA 95201 - <br />