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ApplicationsWhitae Processed WhenSubmittedProperlyCompleted. Be_ SureTo SignTheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) �( SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT I <br /> LIQUID WASTE <br /> Applicatippn is Hereby made tg car on b sin in the' ri dictional area of the S. Joaquin-Local Health District <br /> vi Business Name (DBA) L1��1 L �� .Q Address �S a ��� r .L•. L P ����-�L, <br /> iOwner Address - <br /> :;.Firm Partners, Addresses a Txel hone Numb rs <br /> IL Business Telephone No. V a-- Emergency Telephone No. <br /> Contractor Licence-No.- I' qq <br /> �{ <br /> L Applicants Name (Pr ni t) L C ' - Title <br /> Please check Applicable Category,P-7)and Fill In the Required Information , , ) <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19- J� Disposal Sites- <br /> Description(Make/Yr., Color) l� <br /> Serial No. I� CAL.License No. CAL" License Renewal No. <br /> 'Capacity'_ Gal,-Weights&"Measures No~~ --- <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD I� <br /> 'For July 1,- —June-30, <br /> FNo. of Vehicles Stored IM ` <br /> No. of Chemical Toilets Stored <br /> r _ <br /> 3. ❑ PERCOLATION TEST <br /> # .S. or R.C.E. Name R,S.or R.C.E.No. <br /> Test Location l� Test Date/Time <br /> 4. %PERMIT J� `� <br /> �t e <br /> Job Add ress7Location -�p = <br /> Owner-,Sukj. &j Il l N f-- r V% `T Address r 1- <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT w I <br /> ❑ PERMANENT ❑ TEMPOR"ARY NEW ❑ REPAIR ❑f!ER <br /> 5. 11 CHEMICAL TOILETS Forbuly 1, -June 30, 19 <br /> Type Construction Disposal Site - <br /> �No.of Units Equipment Storage/Cleaning Location(s) t ' ► y- - <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ;G <br /> Operator Namey_.-.- -Where Certifled— -(� <br /> Plant Location <br /> . r <br /> Plant Capacity ' 1 I� Y No. Units Served.r <br /> 7. 11 LAUNDRY -For-July 1, -Ane 30, 19 '"'' '�°""* �-��s=W `- ..� •.��'� >t'xr <br /> SIZE:,O '❑YLess Than 1,000 Sq. 4t., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> fi } <br /> , <br /> arc--�� .I .t <br /> I hereby certify that �l 11avP, repared this application and at the work will be done in accordance with San Joaquin County r <br /> ( ordinances, sta -IavyS, a roles an re ulatl Ansthe S Raqliein Local Health District.-� � <br /> 'APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> FCC i9 Due: ❑ ANNUALLY ❑ PER UNIT_ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By. July'31 <br /> I BILLING REMITTANCE REMIT <br /> $ <br /> BASE EXPLANATION S DATE ATE fj REMITTED AMOUNT DUE AMOUNTD S <br /> + FEE qS _ <br /> 1 LESS <br /> PRORATION I�` G 1,kVr ' Y / I <br /> PLUS I I t <br /> ` PENALTY 6 I 5 <br /> OTHER <br /> i <br /> I OTHER <br /> ----- fes• -9) 3� � _ ? _1 ,{s _..,..._._ ..� �, �' <br /> Received by Date k Receipt No— �+ Permit No. r -Issuance Date ailed Delivered. <br /> APPLICANT—RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Bo=2DO9 STOCKTON,CA 95201 <br /> SII '� <br />