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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLI ATION <br /> (Far Non-Transferable;Revocable;and Suspendable) / SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT f <br /> LIQUID WASTE ._ _ <br /> Applica ' n is hereby made torry on business in the jurisdictional area of the San Joa m Local Health Distric ; <br /> F Business Name{DBA � Address 7 S b t ok_-d + <br /> z Owner Address M <br /> J Firm Pij� hers, Addresses and Telephone Numbers 4(3 R n <br /> M Business-Telephone No, Emergency Telephone No. <br /> Contractor Licence No. AJ <br /> w <br /> �. <br /> LApplicants Name (Print) Title ; Date x -- <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- t <br /> Description(Make/Yr., Color.) I <br /> Serial No. fe' CAL. License No. ^ M CAL. License Renewal No. <br /> Capacity t Gal.,'.Welghts & Measures No. �' <br /> cw <br /> Equipment Parking Address•'~-�-----W-�--� �F�-_ -- <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> - 7 <br /> No. of Chemidal Toilets Stored ' <br /> dr <br /> 3. ❑ PERCOLATION TEST t��j � � � � =. Y. <br /> R.S. or R.C.E.(Name R.S.or R.C.E. No. <br /> Test Location E Test Date/Time <br /> 4. ElSANITATION PERMIT k <br /> Job Addr slLoca ion L e 3 <br /> Owner ` Address 45�j 7- W A-49t <br /> Ul-15EP C TANK' +0 CESSPOOLS ❑ LEACHING FIELD`"'GI] SEEPAGE PITS ❑PACKAGE PLANT <br /> ❑ PERMANENT �0 TEMPORARY ❑, NEW ❑ REPAIR ❑ OTHERv . <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 1 �1 <br /> Type Construction x I :t Disposal Site <br /> No. of UnitsEquipment Storage/Cleaning Location(s) <br /> S. ❑ PACKAGE TREATMENT PLANT r July 1, -June 30, 19 J � WhereCert <br /> Operator Name ,> .:. ified :. <br /> Plant Location <br /> Plant Capacity .,r No. Units Served <br /> 7.. 11 LAUNDRY For Ju4 1, -June 30,,19 ., <br /> SIZE: ❑ &ss Than 1,06 Sq. FL, ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 3 <br /> ' I `ereby certify [hat I have prepared this application and that the work will be,ddone' accordance with San Joaquin County <br /> r ordinances, stAte laws, and rules and regulations of the San Joaquin Local Heath District. ,# <br /> APPLICANT'S SIGNATURE X <br /> !!! FOR DEPARTMENT USE ONLY # <br /> Fee IsDue: ❑ ANNUALLY_j. E[PER UNIT ❑ PER SITE 11EACH 13January 1 &Re eive�d'By`January 31_ ❑ July 1 &Heceived By July 31 <br /> REMIT <br /> BASE i E7tPLANA'TION' --,—BILLING_ REMITTANCE _ R AMOUNT DUE CHECKED <br /> ?¢ <br /> - -- _ . DATE - DATE REM;',,EAMOUNT <br /> FEE �, <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALT .L.. - r ,Ik <br /> OTHER -- - - # <br /> OTHER <br /> Received by - Date ',Receipt No. - Permit No f Issuance toMailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES— 1601 E.HAZELTON AVE.,P.O:Box 2009 STOCKTON,CA 95201 <br />