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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> PARCEL MAA ftDC-$4.-5 (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> DVvE�ct<yL7 L L��;E Z A�'PLt c t�r t car.( LIQUID WASTE <br /> A,,PL,•-Aair�t-c Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> �;rosiness htame � 1-I E N R"r V t k.-I.-A tv u t=-',e,-. Address <br /> i Owner jAmES PiKtc F- Address I41LINDA PL^CP t -T'RAC-'( Grp 9S3-7 (e, <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) A'T E Title GtYIL- Date OC-708 F U(o 198(0 <br /> 4 3 NIA-Tllt��ccv p� zt�, �o I CR Z O CA=- � (1SS4- <br /> Please check Applicable Category(�-7)a-, Fill in the Required Informs ion :3 �1+rE` PHnN� (2a�1 94g-79So <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) k r PHo�,E zoo) arc -4tSq <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 Gal., Weights & 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 /> 3. 0 PERCOLATION TEST PARci=�_ MAP DC, - talo-S,DW>`�t•IN� GLv�'1�P APPt_t: Aito,-t <br /> -R'S^or R.C.E. Narpe r At-T E R- E. ► -fl-S--or R.C.E. No. IIS 4- <br /> Test Location COB- -13. OF 'T"E 1N'trR�+rCTic?i`1 8F Test Date/Time �oFit�� IC���t3C. • RE�+D ifl� tI:�� ••�4p`et�-{sl��Z]YE <br /> 4. C3 SANITATION PERMIT co r2^L I,^—n4N '`�Jfl t_''LR cN R o,�J ✓,��� t ��'?/2ic �aiAv%�il�� <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site _ <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-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 /> ❑ 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 County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE .:;<�,q.3 •�� O <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <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 2009 STOCKTON,CA 95201 <br />