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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> IAPPLICATION <br /> f� (For Non-Transferable;Rerocable;'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-P,I=RMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on busi sss in-t jurisdictional area of-the-clan Joaquin Local He It Distncta, r <br /> y Business Name(DBA) '� `� H AddressYi �r� J� � �� <br /> �- Address - <br /> z Owner+�.., \ ,, <br /> J Firm Partners, Addresses a T 11h hone Numb rs -• <br /> aBusiness Telephone.No... Emergency Telephone No. f <br /> Contractor Licence No. - <br /> .,.y, r� �•. r^ <br /> �Applicants NamejPrint) f L L� Title _ ate.. <br /> E " please check Applicable Category�(1-7)and f=ill in the Required Information <br /> 1.i ❑.••PUMPER VEHICLE PERM I -REGISTRATION (FOR EACH VEHICLE) <br /> =f t <br /> �-ForJulyY1 'June 30,-19 a r` — Disposal Sites <br /> Description(Make/Yr.,Color} J <br /> Serial No. CAL. License No., ,-,CAL. License Renewal No. <br /> Gapaeity - ' -Gal._.Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 �! <br /> No. of Vehicles Stored I� ''" <br /> Nv. of Chemical Toilets Stored. ' ' <br /> ILI <br /> 3. ❑ P'E'RCOLATION TEST i <br /> r' <br /> I oFr_`C.E.No- <br /> R.S. <br /> or R.C.E. Name ;R. <br /> - -- <br /> Test Location �! Test DAte/Time f 1f s o t <br /> I <br /> 4, 11 SANITATION PER 1 <br /> Job Address/ ocation <br /> Owner - d c } Addres - <br /> ' i �- � ❑ PACKAGE PLANT _1 <br /> El SEPTIC TANK ❑ c8SSPOOL `�EACHING FIELD SEEPAGE PIT�,;�I W <br /> c ❑-,PERMANENT ❑ TEMPO�R 4RY= �Lu NEW �'}�'` REPAIR A4 "OTHER ! -� <br /> 45i❑ CHEMICAL TOILETS 'Folz July 1, -June 30! 19 <br /> Type ConstructionDisposal <br /> Site- fir- <br /> a/Cleaning'Locallol.of Units Equipment Stora tion(s <br /> ) <br /> (i. ❑ PACKAGE TREATMENT PLANT For July T,-June 30, 19 <br /> 1-z �- <br /> Operator Name �� <br /> `' , 1� Whe e.Certified�� <br /> I Plant Location <br /> x <br /> } I�� No. Units Served <br /> Plant Capacity Jf <br /> 7„�❑.LAUNDRY For July 1, -June 30, 19- \ - <br /> SIZE: l❑ Less Than 1,000 Sgl[Ft., ❑ More Than 1,000 Sq. Ft. . <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. k <br /> Morrie rorlicenaedagent'saignitu►ncerdfie�Et�fWbwinp "IC thatirtN►eperformance ofthe work for wNchthis permit isissued,ishaltnotemployaRypersen <br /> in'§&h:manner as to become sub 040 woskinaff-5 eompri satioii fawn at eldftmilL , .q a i <br /> Con;rattor's <br /> hi or sub eorrtracdrig signennr perb'pes-qie fd ng; #r;eitlfy tttat'in he pettbrmattce of the work for whish tR9spermit is tissued,i shall <br /> I - emplo persons subject to wprkman'S Campensa4tan iaws-0f CaTifptltia.' "�, ” <br /> { t I hereby ce that I� ave-p e 'par this applican and that.the work Will be done in accordance with San Joaquin �ounty� <br /> I <br /> ordinanc a �y and les an ul d .o s f he n Joaquin Local Health District, 1{ _ <br /> it y+0� <br /> APPLICANT'S SIGNATURE <br /> r <br /> FOR DEPARTMENT USE ONLY- ; <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> C I. REMIT <br /> A BILLING' REMITTANCE .� AMOUNT DUE CHECKED <br /> BA.Sp EXPLANATION .DATE - .DATES REMITTED IAMOUNT _ <br /> y, (� O <br /> FEE `;�.�d <br /> LESS <br /> PRORATIONPLbS <br /> ffff { <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received b -wz � <br /> - Receipt NpY1 } Permit'G ,r lssua_ce;Date Mailed Delivered" <br /> s t .. i.-� /�^. <br /> APPLIC NT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1691 E.HAZELTON AVE.,P.D.Box 2009 STpCKTON,CA 95201 - # <br />