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APPLICATION <br />(For Non-Transferable, Revocable, and Suspendable) <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />on business_iii=risdictional area of the Sm Joaquin Local Heagsi ilict <br />dt'''4 Address 0.454frfr.26. <br />c <br /> <br />Address <br />0 <br />' <br />Application hereby made to car <br />, - Business Name ( BA) <br />Owner - <br />Firm Partners, Addresses and Telephone Nu bers <br />SEPTAGE <br />i <br />:I Contractor Licence No. <br />c .. _ , -,1 471r : Title Date 9-.2 v -i/ L Applicants Name (Print) ..49., ..... — <br />Please check check Applicable Category (1-7) and Fill in the Required Information CIJ <br />_..L <br />1. 0 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />For July 1, June 30, 19 Disposal Sites <br />Description (Make/Yr., Color) <br />Serial No. CAL. License No. CAL. Liccnse Renewal No. <br />Capacity Gal., Weights & Measures No. <br />Equipment Parking Address <br />2. 0 PUMPER YARD <br />For July 1,_ June 30, 19 <br />No. of Vehicles Stored <br />e 44...i...../ ze _ge.0.7 „,..d'eve_ • Address _1143 5e2—,2t—inuegt-f-ke <br />0 LEACHING FIELD i _Orgi.EPAGE PIT 0 PACKAGE PLANT <br />0 NEW 2--REPAIR 0 OTHER t_ <br />For July 1,- June 30, 19 <br /> Disposal Site <br /> Equipment Storage/Cleaning Location(s) 0 <br />0 PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br />Operator Name Where Certified <br />Plant Location <br />Plant Capacity No. Units Served <br />0 LAUNDRY For July 1, - June 30, 19 <br />SIZE: 0 Less Than 1,000 Sq. Ft., 0 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 rul nd regulations of the San Joaquin Local Health District. <br />APPLICANT'S SIGNATURE X <br />FOR DEPARTMENT USE ONLY <br />• <br /> fl SITE 0 EACH 0 January 1 & Received By January 31 0 July 1 & ReceLved By July 31 <br />BASE EXF'LANAT1ON BILLING <br />DATE <br />REMITTANCE <br />DATE <br />$ <br />REMITTED <br />AMOUNT DUE <br />REMIT <br />CHECKED Nsi <br />AMOUNT <br />• <br />FEE 1,1 q 5 c.)-\ 3 14 • <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER 11 <br />OTHER <br />I 33 4,3 GI _ 1;:312 <br />ket mrkr.illata <br />1 <br />Liallerorl 11Alivwreati <br />Business Telephone No. __3Aer Emergency Telephone No <br />No. of Chemical Toilets Stored <br />3. 0 PERCOLATION TEST <br />R.S. or R.C.E. Name R.S. or R.C.E. No. <br />Teseation Test Date/Time <br />4. SANITATION PERMIT <br />Job Address/Location . I 2-4e <br />Owner a4.4s-04,11 <br />0 SEPTIC TANK 0 CESSPOOL <br />PERMANENT 0 TEMPORARY <br />5. 0 CHEMICAL TOILETS <br />Type Construction <br />No. of Units <br />eceived by Date <br />1601 E. HAZELTON AVE., P.O. Sox 2009 STOCKTON, CA 95201 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES