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APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) - <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 /> r Business Name (DBA) �`iCTlOII s? ���titi r• Tnnl� 4eT-Ili P Address 4645 T i ldrFY1T i nr-A <br /> Lr = <br /> Dwner 1. c. 1'4Ci70Tta11� Address Samp <br /> irm Partners,Addresses and Telephone Numbers <br /> n Business Telephone No. 931-0497 Emergency Telephone No. Oi-3-7-4097 C <br /> a <br /> �}}} Contractor licence No. 303171 ) <br /> yyyapplicants Name (Print) 1. R. McDonald Title 7".r Gr Date <br /> lease check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR.EACH VEHICLE) Ir <br /> G <br /> For July 1, June 30, 19 Disposal Sites <br /> LDescription(Make/Yr.,Color) <br /> Serial No. CAL.License No. CAL. Liccgse Renewal No. <br /> Capacity Gat.,Weights&Measures No. <br /> Equipment Parking Address <br /> V2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored <br /> LNo. 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 PERMIT - <br /> Job Address/Location v <br /> LOwner— drip_ . n � Atldress� y <br /> SEPTIC TANK L1 CE POOL 44 LEACHING FIELD SEEPAGE PIT ❑ PACrKA6E PLANT <br /> ❑ PERMANENT ❑ TEMPORARY "(NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 { <br /> V Type Construction I Disposal Site <br /> No.of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> LOperator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> r SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> V <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, and rules an gulatigps of theS JJ aquin Local^ Health istr' <br /> APPLICANTS SIGNATUREX <br /> V <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY O PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BILLING. REMITTANCE S <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> �[ AMOUNT <br /> L FEE I3ys•n <br /> LESS Y <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Oate Receipt No. Permit No. Issuance Date Malted Delrveretl�' <br /> - APPLICANT—RETURN ALL COPIES TO- ENVIRONMENTAL HEALTH PERMIT/SERVICES 16M E.HA FLTON AVE.,P.O.Boz 2089 STOCKTONVN,,CA SIMM <br />