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APPLICATION <br /> ( Jon-Transferable, Revocable, and Suspendable� SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application 1s by made to rryonbusl'Dfssirthe jurisd' tonal area of the San Joaquin Local Health District Q <br /> �! Address d IS.-I- 7 L 'Z .7rsG. <br /> DwneIimsiness Name(D I 6 �. <br /> owner c Address <br /> in Partners, Addresses and Telephone Numbers <br /> �isiness Telephone No. 36 S ��O 5' Emergency Telephone No. <br /> Jontractor Licence No._ <br /> - <br /> "oplicants Name (Print) - - Title Date ��"� 11 <br /> ease Check Applicable Category (1-7) and Fill in the Required In ormation v <br /> Ir ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) tl� <br /> For July 1, June 30, 19 Disposal Sites <br /> ascription(Make/Yr.,Color) -- - <br /> CAL. License No. _ CAL. License Renewal No. <br /> n rial No. <br /> Capacity Gal.,Weights &Measures No. - -- <br /> Iuipment Parking Address - <br /> ❑ PUMPER YARD . <br /> For July 1, June 30. 19 <br /> No.of Vehicles Stored <br /> 3.of Chemical Toilets Stored <br /> S ❑ PERCOLATION TEST <br /> R.S.or R.C.E.Name R.S.or R.C.E.No. <br /> st�Lo�tion Test Date/Time <br /> L7 SANITATION PERMIT , J _ <br /> Job Address/Location I - O �•LtvH <br /> Aj <br /> w �e ^ n Address �"I' <br /> �^Y/$EIPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SWAGE PIT ❑ PACKAGE PLANT <br /> W PERMANENT ❑ TEMPORARY ❑ NEW IR ❑ OTHER <br /> 6. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 Q <br /> ype Construction Disposal Site t\ <br /> .o.of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> perator Name Where Certified <br /> _lant Location <br /> Plant Capacity _ No. Units Served <br /> T. ❑ LAUNDRY For July 1,-June 30, 19 <br /> IZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> TJ 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 unty <br /> ordinances, state laws,and rules an ulations of the an Joaquin Local Health District. <br /> .PPLICANT'S SIGNATU REX �O v� -- -- <br /> FOR DEPARTMENT USE ONLY <br /> F!!15 DUG:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH <br /> January 1 6 Received y ary 3 July 1 & erred By July 31 <br /> REMIT <br /> BASE E%PLANATION BILLING REMITTANCE $ MOUNT DUE CHECKED <br /> DATE DATE REMITTEAMOUNT <br /> [.�r <br /> FEE t0 T <br /> LESS <br /> PRORATION — <br /> PLUS <br /> PENALTY <br /> ` OTHER <br /> I OTHER <br /> Received BY Date Receipt No. Permit No. Issuan a Date Mailed Iivere0 r <br /> 1 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 3311011 <br />