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Applications Will Be Processed When Submlited Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION ' <br /> (For Non-Transferable, Revocable, and Suspendable) t: <br /> jl ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is herebymadeto carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) i,"" ROPI z_,0,V J w C_ _ Address U>1!v Sp ] 13 W W ALAO''V-F pvs/?A. <br /> a Owner a2,&/A L-0 �• /-LC,<-4AT- Address ed diax q1"7 /3g`{S Lv . G_clmi_ow-'F Gl1�v+f 12b <br /> Firm Partners, Addresses and Tgelephone Numbers <br /> Business Telephone No. 7{ �`��'7 Emergency Telephone No. �" 2'e- <br /> a. Z7 <br /> Contractor Licence No. <br /> L Applicants Name (Print) 00,01j6 LG d, E-- K&err Title ��/ �`'^� Date 1/—/0 <br /> Please check Applicable Category(1-7)and Fill in the Required Information 1 <br /> 1. 1:1 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) d <br /> For July 1, June 30, 19 41 Disposal Sites 11 <br /> Description(Make/Yr., Color) _'I. f <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity ''Gal., Weights & Measures No. <br /> Equipment Parking Address LV <br /> 2. ❑ PUMPER YARD r <br /> For July 1, June 30, 19 _ <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST i <br /> R.S. or R.C.E. Name II R.S. or R.C.E. No. <br /> Test Location - Test Date/Time <br /> 4. IR SANITATION PERMIT i9 S <br /> Job Address/Location 13 7Y5,i &,m i_N sv& AV no • w <br /> Owner J)_aALb 1.D X A-7- Address _go. gy3t q0 J�Ytf S L,J l,>X1ty�r GRriLx �t�. <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 1 Disposal Site <br /> No. of Units :r Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name I` 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� <br /> I hereby certify that I have prepared this application and that the work will be done in accordance wit a Joaqu n vpint <br /> ordinances, s and regulations of the San Joa i I Health District. �J <br /> 1 <br /> r ' <br /> APPLICANT'S SIGNATURE X <br /> I� FOR DEPARTMENT USE ONLY <br /> i <br /> Fie Is Due: 13ANNUALLY LJPER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received y JanuVry 31 ❑ J�N&Re ei y Juiy 31 <br /> IT <br /> AM <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION OUN OLE CH KED <br /> I� DATE DATE REMIT D ftAM NT <br /> FEE S� h I <br /> LESS . �r <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ,II <br /> Y <br /> OTHER <br /> G <br /> Received by Date i Receipt No Permit No. Issuance Date r NNiled Delivered <br /> Ir i <br /> APPLICANT—RETURN ALL COPIES',TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE., ox 2009 STOCKTON,CA 95201 <br />