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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. T <br /> sr f APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE I <br /> r LIQUID WASTE +� <br /> 9 Applicati is hereb ade to carry on business in the jurisdictional area of the San Joaquin Local Health District An <br /> F Business Name <br /> a a Owner . GtL�/r1� Address � � <br /> ` .Firm Partners, Addresses and Telephone Numbers <br /> a� Business Telephone No. 146 Emergency Telephone No. <br /> a s <br /> aContr�or-Licence�No. 3 <br /> L Applicants'Name(Print).rye- Title Z757, Date <br /> Please check Applicable Category (1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH XEHICL"E] . <br /> For July 1, June 30, 19 Disposal Sites <br /> ra y�;r <br /> Descriptionf(Make rICoo.w ir) r <br /> r Serial No. CAL. License No. �:`, :j .'-PEAL Lfiense Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> ( 2. ❑ PUMPER YARD 1 <br /> For July 1, June 30, 19 <br /> } No.of Vehicles Stored <br /> ( No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.-Name R.S. or R.C.E. No. Or <br /> Test Location "_ � Test Date/Time <br /> 4. SANITATION PERMIT ' <br /> Job Address/Location *.7a`� �'j�/� Rr-7"W <br /> Ownerld A476=, Addres�ps� e r <br /> h ❑ SEPTIC TANK C1C SPOOL ❑ LEACHING FLED SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEWREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS f, For July 1,1-June 30, 19 <br /> t Type Construction Disposal Site' s J <br /> No. of Units Equipment Storage/Cleani g Location(s) <br /> 6. El <br /> PACKAGE TREATMENT PLANT For July 1, -June<316, 19 <br /> Operator Name e . i � Where Certified <br /> I Plant Location R V-1, 1 <br /> Plant Capacity �f '_ Noii. nits Served <br /> 7. 11 LAUNDRY For July 1, -June 30, 19 i <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. #! <br /> ❑ DRY CLEANING, Chemicals Used/Amount/o. t <br /> �►—r.1at - <br /> � . /F �. <br /> 1 hereby cer[ify Inialhave prepared this application and-that that-the work wiilfbe done in accordance with'San Joaquin County <br /> ordinances, state laws, a es and re ulatipgriss of the San JoaquinlLocal Health District. <br /> APPLICANT'S SIGNATURE " �" t <br /> 4 <br /> l� <br /> G r 0 SZ 17 5F <br /> • l!+i+�+ FOR-DEPARTMENT USE ONL1�Y <br /> i Fee is Due: ❑ ANNUAL PER UNIT ❑'PER SITE ❑ EACH - ❑ January 1'g <br /> &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REM4 TTANCE �$y�� ; gMOUNT DUE CHECKED <br /> C * DATE DATE REMITTED ��"�; AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ' t <br /> PLUS <br /> PENALTY \ <br /> OTHER JK <br /> I <br /> OTHER <br /> P <br /> I # 7q _79.S'k <br /> Received by - Date' i'- A#, Receipt No a Permit No L„-j = - }Issuance Date%',71 Mailed' Delivered <br /> 7, 1 <br /> APPLICANT-RfLURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ISM E:RAZELTON AVE..P.O.9oY2009 r STQGKTON,CA 45201— <br />