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Emergency Telephone No. <br />1 <br />Date Title <br />CAL. License Renewal No. <br />c <br />ition <br />Where Certified <br />No. Units Served <br /> EACHFee Is Due: annually PER UNIT <br />AMOUNT DUEEXPLANATIONBASE <br />CM-FEE <br />OTHER <br />OTHER <br />APPLICANT'S SIGNATURE X — <br />Received by Date <br />- APPLICANT—RETURN ALL COPIES TO: <br />__________CAL. License No. <br />Gal., Weights & Measures No. <br />BILLING <br />DATE <br />______R.S. or R.C.E. No. <br />Test Date/Time-------------- <br />C July 1 & Received By July 31 <br />REMIT <br />CHECKED <br />AMOUNT <br /> CESSPOOL <br /> TEMPORARY <br />Delivered <br />STOCKTON. CA 95201 <br />4 <br />FOR DEPARTMENT USE ONLY \\- <br /> PER SITE EACH January 1 & Receivey^January 31 <br />EMITTED} <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />Ct I <br />____________65352 <br />Receipt No. Permit No. <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />REMITTANC <br />DAI£. <br />■ss <br />0fsEEPAGE PIT PACKAGE PLANT <br /> REPAIR OTHER <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br />--------------------------------- <br />_______________ _— <br />Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />APPLICATION o 7^3 <br />(Fu. Non-Transferable, Revocable, and Suspendable ‘ <br />ENVIRONMENTAL HEALTH PERMIT : <br />LIQUID WASTE <br />' >n is hereby/oade to carry on business in the jurisdictional area of the San Joaquin Local Health District Address 2^1 <br />_________________________________Address _ ________________________________________ <br />SEPTAGE <br />P— <br />Issuance Date Mailed <br />1601 E. HAZELTON AVE., P.O. Box 2009 <br />Application^ h^reby| <br />Business Name (DBA) <br />z Owner <br />B Firm Partners, Addresses and Telephone^Numbers <br />| Business Telephone No. <br />j Contractor Licence No.__________________ <br />* Applicants Name (Print)/*7^Z €~// Q--------------------------------- <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. <br />Capacity <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 <br />Test Location ------------------------ <br />4. SANITATION PERMIT <br />Job Address/Loi <br />Owner__1/*^-__________,----------------- <br />Aseptic tank □ cesspool '^leaching <br />"IMPERMANENT □ TEMPORARY ^0 NEW <br />*5. □ 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---------------------------------------- <br />Plant Location ___ <br />Plant Capacity <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 />/O/Od tbuu&x Ste-tLSi. <br />_ Address <br />FIELD '