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I"I I V Applications W!1it)`recessed When Submitted Properly Completed. Be Sure10Sign The Application. Y <br /> Jsu SEP 7 1379 APPLICATION ;erg 10 21 <br /> (tion-Transferable, Revocable,and Suspendabit SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> .SAN <br /> �,qJ�O'TTAQ tU�I'NeTLO�/C�AL LIQUID WASTE . <br /> HEAPPI <br /> AL i�PioPk-%1leoyrTiade to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> m Business Name (DBA) _ 006'Co C E Address GTH 61, <br /> i Owner !>� h C0S �� Address 4(?e-2 JZ40 <br /> Firm Partners. Addresses and Telephone Numbers _ b <br /> u Business Telephone NEmergency Telephone No. <br /> Contractor Licence No. W <br /> L Applicants Name (Print) Title Date W <br /> Please check Applicable Category (1-7)and Fill 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. '\ <br /> Capacity Gal.,Weights&Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored (A <br /> No. of Chemical Toilets Stored _t <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. flame P.S. or R.C.E.No. <br /> Test Location Test Date/Time <br /> 4. 7.SANITATION PEHMIT <br /> Job AddreLocation '+') 8 Z �n 4� �IWJ�4� / A/4`&C / <br /> Owner � Q'Y1 ' Address _& e. <br /> J9 SEPTIC TANK ❑ CESSPOOL X LEACHING FIELD ❑ SEEPAGE PIT 0 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY Q NEW ❑ REPAIR '❑ OTHER a <br /> S. Q CHEMICAL TOILETS For July 1,-June 3Q.19 �I <br /> Type Construction Disposal Site (rll <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 <br /> Plant Capacity No.Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 . <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., p More Than 1,000 Sq. Ft. <br /> ❑ DRY GLEANING,Chemicals Used/AmounUMo. <br /> / <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, an les and/egulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Anewee By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> -DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ' <br /> PLUS q <br /> PENALTY <br /> OTHER V 1 <br /> OTHER r <br /> /$J <br /> -79_i �ifg��y <br /> Received by Date Receipt No. Permit No. Issuance Date Manee Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Gar 2009 STOCKTON,CA 95201 <br />