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APPLICATION J -.���/���/�}}}},////�
<br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE
<br /> �- ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE
<br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District
<br /> k„9usiness Name (DBA) FL//OA L.1;2;ih'.4.es•,l c/o Address. �T—��• //1.fi��TT STS[/
<br /> z Owner Address
<br /> #
<br /> {' Firm Partners, Addresses and Telephone Number
<br /> kBBs
<br /> usiness Telephone No. Emergency Telephone No.
<br /> ontractor Licence No.
<br /> 1 Applicants Name (Print) Foo te0 W"'> _ Title TCrC.fi./7 Date
<br /> Please check Applicable Category (1-7) and Fill in the Required Information I
<br /> •ll. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) W
<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 _ Get.,Weights 8 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 /> 1..3. ❑ PERCOLATION TEST
<br /> R.S. or R.C.E. Name R.S.or R.C.E. No.
<br /> Test Location Test Date/Time �1CPJ
<br /> 4.0 SANITATION PERMIT Y
<br /> 'Job Address/Location SCJ C• �Aiw/ ST SYF1Td.tJ Q
<br /> Owner jc=ze 'es-IA/0 Address .S'T`4457AE -WW,.Cl -TP--
<br /> 11
<br /> P❑ SEPTIC TANK ❑ CESSPOOL ❑. LEACHING FIELD ❑ SEEPAGE PIT 13 PACKAGE P NT
<br /> ► )
<br /> O PERMANENT ❑ TEMPORARY 1113NEW REPAIR 2 OTHER 4KP77 C/TJX SG�daie
<br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ,pdgdp®,r/ -sEF� �-41"i" SYS-2zxf(`A
<br /> 1
<br /> Type Construction Disposal Site
<br /> ,..No. of Units Equipment Storage/Cleaning Location(s)
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July t, -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 /> Dom, (tj({ay-. d Am unt/MO vaMnvnr. Ic>4i, e . p
<br /> In such
<br /> as iq et Ole fot�c-p;, „ ,,,�,.M,, ati::�!ga�s a;Ca chnia.the erfermanceoftheworkforwhich it!ispermit is Issued,laballnotempbya!rypersOn
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<br /> .2 or sub. ,nhBcu,.,3 S;j,,,t.,ye 'ce:l;tfes ;;,;, foilcwing: '1 certify that in the performance of the York for which this permit is issued.1 shag
<br /> . .CaW1 ypQrsors suznu;:,;artcmans 6amp6;tW:,tioa:axus ct Cah!arrlia”
<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, and rules and
<br /> regulations of San Joaquin Local Health District. ti
<br /> `APPLICANTS SIGNATURE X � � A--r�
<br /> r FOR DEPARTMENT USI!ONLY
<br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 is Received By January 31 ❑ July 1 is Received By July 31
<br /> REMIT
<br /> BILLING REMITTANCE $
<br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED
<br /> ` p AMOUNT
<br /> FEE J ml D
<br /> LESS
<br /> PRORATION -
<br /> lax, PLUS
<br /> PENALTY
<br /> OTHER
<br /> ►. OTHER
<br /> 1hoit -7 66 -Y
<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 20051 STOCKTON,CA 95201
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