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... T_ <br /> Applications Will Be Processed When Submitted roper <br /> APPLICATION • f <br /> _ (For Non-Transferable, Revocable, and Suspendable) w< SEPTAGE <br /> allENVIRONMENTAL HEALTH PERMIT— v �'' <br /> LIQUID WASTE <br /> t . <br /> Application is hereby made to car on-business In the junsdlclional area of the San Joaquin Local Health District" � i <br /> � ki.9 Address <br /> mBusiness Name (DBA) Address <br /> aOwner <br /> J Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> a Business Telephone No. i{ <br /> a <br /> Contractor Licence No. 77-S744 <br /> Title Dale 11 <br /> Applicants Name (Print) i Jq <br /> and Fill In the Required Information <br /> Please check Applicable Category(1`-7) I <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ` <br /> June 30, 19 Disposal Sites <br /> For July 1, i <br /> Description(Make/Yr., Color) CAL. License No. CAL.License Renewal No. <br /> Serial No. <br /> Capacity - Gal.,Weights &Measures No. ( ' <br /> 0 <br /> Equipment Parking Address _ <br /> 2. ❑ PUMPER YARD t. 3, twi <br /> For July 1, June 30;19 <br /> No. of Vehicles Stored 1 <br /> No. of Chemical Toilets Stored s <br /> 3, ❑ PERCOLATION TEST R.S.or R.C.E.No. <br /> s ; <br /> R.S. or R.C.E. Name ` <br /> est Bate/Time <br /> Testi^Looc�cation <br /> q, LTSANITATION PERMIT /(I 1.-� <br /> Job Address/Location 1 <br /> Address r <br /> Owner11PACKAGE PLANT, t <br /> Cl SEPTIC TANK` ❑ CESSPOOL [}'�ACFiING FIELD1EEPAGE PIT ETHER �`� LL <br /> 9-PERMANENT ❑TEMPORARY ❑ NEW C TEPAIR Via— AL1 S�} IJf i� <br /> w.,.�........ �,. -. ,.. ..w- <br /> 5. ❑ CHEMICAL TOILETSFor July 1, -June 30. 19 xf <br /> Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 1:1 <br /> g, PACKAGE TREATMENT PLANT For July i, <br /> Type Construction -June 30, 19 _Where Certified <br /> F <br /> Operator Name <br /> Plant Location ' 1 <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -"June 30, 19 ( f <br /> SIZE: 11Less Than 1,000`Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. F r _ •; x,4 F~ti <br /> re ared this application d that t ork wjl+be done in accordance with San Joaquin County t, <br /> I hereby certify that I ha p p ( ' <br /> ordinances, state laws, d Ind r lations of a an J qu' Loca Health District, f I <br /> APPLICANT'S SIGNATURE X +� <br /> r3 ! a <br /> FOR DEPARTMENT USE ONLY <br /> " PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 �.❑ July 1 &Recekved By�JuVy 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ REMIT <br /> _ $ CHECKED <br /> 1-bAT C,' REMITTANCE _ - AMOUNT DUE AMOUNT <br /> BASF. --EXPLANATION ' r. a A REMITTED""- <br /> . is "b11TE` �` s . DATE ;�``��r <br /> �s <br /> FEE �♦ €r / } 3 <br /> C LESS - c <br /> PRORATION 5 <br /> PLUS T <br /> PENALTY r <br /> OTHER �w <br /> OTHER, <br /> -.„4.. .. a.:,,r . ..-...., w a..-,o.-.r*.••-„ter' '� _ . .e .«,.- 1 <br /> Date Receipt No. <br /> Permit No Issuance Date Mailed Delivered 1 } <br /> ' '16SF1 E.µAZELTON AVE.,P_O.B05,20099 <br /> STOCKTON,CA 9 201 <br /> Received by - <br /> APPLICANT—RETURN ALL COPIES TO: ENYkRONMEN7AL HEALTH PERMITlSERYICES <br /> 1,r. <br />