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u v <br /> Applications Yip B�Processed When Submitted Properly Completed. Be Sure o !G <br /> Sign The Application. 1 <br /> / <br /> SEP 7 1979 APPLICATION 3y <br /> Non-Transferable, Revocable,and Suspendab. 0 tA3<� SEPTAGE <br /> SAN JOAOUIN V���l ENVIRONMENTAL HEALTH PERMIT T <br /> TSI L, LIQUID WASTE <br /> HEF���atio)I is hereby made to carry on business in the jurisdictional area Of the San Joaquin Local Health District <br /> F Business Name (DBA)�.p/�f'r3r Address e- cpizT <br />? Owner��,.Q.h..--('.Lry-S'-y Address <br /> Firm Partners,Addresses and Telephone Numbers I y/.SO <br /> 0. Business Telephone No. 83G—0 it A !2 Emergency.Telephone No. . <br /> 11 Contractor Licence No. <br />� <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information - <br /> 1. ❑ PUMPER VEHICLE PERMjT REGISTRATION(FOR EACH VEHICLE) - <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(MalfeNr.,Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal„Weights 6 Measures No. <br /> Equipment Parking Address ' <br /> 2. ❑ PUMPER YARD 7� <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. Q PERCOLATION TEST - <br /> R.S. or R.C.E. Name '•• R.S. or R.C.E.No. �C <br /> Test Location Test Date/Time <br /> 4. 14 SANITATION PERMITt� <br /> Job Address/Loca Ion �_ <br /> Owner Address� <br /> I& SEPTIC TANK " ❑ CESSPOOL Q LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT ZM <br /> ❑ PERMANENT- 11 TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site, <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.-bons Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 r <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. .4•' <br /> , <br /> I hereby certify that 1 have prepared this applicationand that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,and <br /> ss,and regula ' s of the Sa otiquin Local Health District. <br /> APPLICANT'S SIGNATURE X (.G{� /�79 ./ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 S Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> o. DATE DATE REMITTED 'l AMOUNT <br /> FEE tLIP5 1 vi rz) /''�` <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER Oil, ,1 <br /> OTHER <br /> '7Q�s Sit&fi ?! <br /> Received by Date Receipt No. ermn No. Issuance DaleeMalted Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTOH AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />