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Appllcstl Ons Will Be�Processed When Submitted Properly Completed..Be Sur+To Sign The.Applicatlon. / 1 , L 1 <br /> APPLICATION ' : f I `� <br /> ( ion-Transferable,Revocable,and Suspendebl / SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ;LIQUID WASTE <br /> Application is herebm mad to carryon business in the jurisdictional area of the San J ujn Local Health Distgtt <br /> a Business Name (DI3 § ����-G�St Address <br /> Owners •/.�N�G �+ Address -- -- -- - <br /> Firm Partners, Addresses and Teleph a Numbers <br /> Q. Business Telephone No. r4 EmergeriLy Telephone No. <br /> Contractor Licence,No. <br /> J <br /> Title _13,.,r..d�PIL/ Date— j''—',L =, l lT <br /> L Applicants Name (Print) <br /> Please check Applicable Category (1-7)and FIII In the Required Informatlon ^- <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) - <br /> For July 1, Jyne 30, 19 - Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. ��_---�' CAC'Licanse NO.-'---_--.. -- —�--CAI!:Licens"anewal.Alq qrq <br /> Capacity ` Gal.,Weights & Measures No. T <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD - <br /> For July 1, June 30, 19 \/ <br /> No. of Vehicles Stored r <br /> No. of Chemical Toilets Stored I <br /> 3. ❑ PERCOLATION TEST _ <br /> R.S.or R.C.E. Name R.S.or R.b.E. No. `r <br /> Test Location Test Date/Time b'I <br /> 4. 1:1, SANITATION PERMIT <br /> i <br /> Job Address/Location �� G � L� ?�� ; y <br /> Owner <br /> EPTIC TANK ❑ CESSPOOL ACHING FIELD ©'SEEPAGE PIT .0 PACKAGE PLANT <br /> P PERMANENT ❑ TEMPORARY ❑ NEW i :❑ REPAift :Q OTHER <br /> S. P CHEMICAL TOILETS For July 1,-June 30. 19' . <br /> - { <br /> Type Construction �;�Disposal Site <br /> r <br /> IJo. of Units Equipmerit`Storage/Cleaning Location(s) I <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-Jurtp30,•19�• '� 1 - <br /> Operator Name 1p - " " Where Certified ' <br /> Plant Location <br /> Plant Capacity 3 No!Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 1.9 .;t,J <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,I` ;rr((p❑ More Than 1,0005q. <br /> 11 DRY CLEAN If;G,Chemicals Used/Alilbdnt/Mo. 1 ) <br /> ... , r dF <br /> f C <br /> I hereby certify that I have prepared this application a4d that the work will be done in accordance with San,Joaquin County <br /> ordinances, state taws,and rulT and r ulations of th Joaquin Local Health District. <br /> 1 <br /> APPLICANT'S SIGNATURE , <br /> F:_EOR DEPARTMENLUSB'ONCY i <br /> Fee Is Due: ❑ ANNUAL Y ❑ PER.UNIT ❑ PER SITE ❑ EAC W ❑ January 1 d Rmen,ed By January 31 ❑ July 1 a Received By July 31 <br /> BIL LIN REMITTANCE S 1 REMIT <br /> BASE EXPLANATION q AMOUNT DUE CHECKED <br /> [•� DATE DATE REMITTED AMOUNT <br /> FEE —J". { <br /> LESS <br /> PRORATION <br /> PLUS Q - <br /> PENALTY <br /> OTHER _ <br /> -Sias r <br /> Received by Date Receipt No. Permd No Inuance Date Mailed Debvered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE..P.O.6o.21109 STOCKTON,CA 95201 <br />