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f Submitted Properly Completed.Applications Will Be Processed When <br />APPLICATION <br />For Non-Transferable,'Revocable,and Suspendable) SEPTAGE <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />Application is hereby made to carry on business in the jurisdictional area of the§ao J0a5{"A Loca H . <br />2pigtrict <br />kdd resS <br />yBusiness Name (DBA) <br />Address <br />aOwner <br />Firm Partners, Addresses a Te ep hop um rs <br />Emergency Telephone No. <br />3 <br />CL <br />Business Telephone No.. 1r <br />Contractor Licence No.. :-_ <br />f <br />Title <br />ate <br />L Applicants Name (Print) 1 7 and Fill in the Required InformationPleasecheckApplicableCategory-( - )_ <br />1, PUMPER VEHICLE PERMIT REGISTRATION (FOA EACH VEHICLE) <br />n'For July 1, June 30 19-L, <br />Disposal Sites. <br />i- Description(Make/Yr.,Color) <br />CAL. License NO. <br />CAL.,License,Renewal No. <br />Serial No: <br />i- <br />v- <br />lGal:7Weights&Measures No: ' <br />Equipment Parking Address <br />2. PUMPER YARD <br />For July 1, June 34, 19 <br />C No. of Vehicles Stored <br />No. of Chemical Joilets Stored w <br />1 3, PERCOL^AT70N TEST R.S. or R.C.E.No. <br />R.S.'or R.C.E.-Namea .. <br />Test Date/TimeyCJr <br />Test. <br />f <br />Location <br />4.- SANITATION PERMIT <br />Job Add r s/LC tion J <br />Addre s <br />Owner PACKAGE PLANT <br />SEPTIC TANK CESSPOOL LEACHING FIELD EEPAGEiPIT <br />OTHER <br />El PERMANENT TEMPORARY NEW EPAIR <br />5. CHEMICAL TOILETS For July 1, -June 30, 19 t <br />Type Construction <br />i r.Disposal-Site v= <br />No.of Units I Equipment Storage/Cleaning Location(s) <br />t <br />6. PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br />Where Certified <br />Operator Name <br />y <br />Plant Location tNo. Units Served <br />Plant Capacity <br />7. ('7 LAUNDRY For July 1,-June 30, 19 <br />SIZE:Less Than 1,000 Sq. Ft., More Than 1,000 Sq. Ft. r '' <br />F-w-......., - <br />DRY.CLEANING,Chemicais.Used/Amount/Mo. <br />i <br />i Ilcation an that the work will be done in accordance with San Joaquin County <br />I hereby Ce, I have prepared this'app <br />ordinances*state lave d ule an},{' regulation pof the S Joaquin .ocaI Health District. <br />APPLICANT'S SIGNATORq <br />x i FOR DEPARTMENT USE ONLY <br />t <br />REMIT <br />Fee IS DUE'. ANNUALLY PER UNIT _ iPER SITE EACH January 1 &Received By January 31 July 1 &Received By July 31 <br />1 y <br />fBILLING <br />REMITTANCE AMOUNT DUE CHECKED <br />BASE EXPLANATION DATE DATE - +REMITTED AMOUNT 0. <br />FEE <br />LESS'ee 5 <br />PRORATION S <br />r PLUS <br />PENALTY <br />e ' <br />I OTHER <br />t <br />OTHER i <br />4ssuance Date fled Delivered <br />t r D to receipt No. Permit No. . <br />I reeeived 6y 1601 E.HA2ELTON AY ., ox 2009 . STOCKTON,CA 95201 <br />APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />1