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VAppllcat(ojl '/JIII Be Processed When Submitted Properly Completed. Be Sure o Sign The Application. / r <br /> APPLICATION 10/ .7 <br /> SL{P 7 1979 (I .on-Transferable, Revocable, and Suspendablt - �Or3 <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SAN Jn•"0U(" ( r <br /> I_ LIQUID WASTE <br /> I-IEALT14P43?9RCR W,4reby made to carry on business in the jurisdictional.area of the San Joaquin at Health District 1 <br /> q Business Name (DBA(—'000?3 nAQ�, AddressT/ �y <br /> Owner i CS <br /> Firm Partners, Addresses and Telephone Numbers - <br /> iBusiness Telephone No. G-��"---0u?-2 Emergency Telephone No. <br /> Contractor Licence No. 1,3 AL? <br /> L Applicants Name (Print) _ Title Date <br /> Please check Applicable Category (1.7)and FIII In the Required Information <br /> 1. ❑ 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. License Renewal No. -n <br /> Capacity _ Gal.,Weights 6 Measures No. _ <br /> 1 <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. ❑ PERCOLATION TEST ' <br /> R.S.or R.C.E. Name R.S. Or R.C.E. No. <br /> Test Location Test Date/Time <br /> 0. A SANITATION PERMITIS� <br /> Job Address/ ocation T ye <br /> Ownprd'�- - AdQress ,F ( (r <br /> D1SEPTIC TANK 11 CESSPOOL AL LEACHING FIELD ❑ SEEPAGE PIT P PACKAGE PLAN 7 <br /> ❑ PERMANENT ❑ TEMPORARY Q NEW ❑ REPAIR ❑ OTHER ^- <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30. 19 _ <br /> Type Construction Disposal Site 6 <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 - C <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 /> r <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 s and regulatons of the SiJoaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 6 Received By January 31 ❑ July 1 d Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE f <br /> BASE E%PLANATION DATE - DATE REMITTED AMOUNT DUE CHECKED <br /> �j AMOUNT <br /> FEE �I4S.pQ Y'S1 QO <br /> LESS - 1 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> J OTHER 1 <br /> OTHER I` <br /> OI7rcI <br /> • <br /> -79 LA <br /> `1 9/- <br /> II��79 <br /> Received by Date Receipt No Permit No. asua ce Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 9520t <br />