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Applications Will Be Processed When Submitted Properly Completed. Be-Sure,Ta Sign Th�e IApplication. APPLICATION 4 (For Non-Transferable,Revocable, and SuspendablV)r,4+fid .3_ (* " SEPTAGE ENVIRONMENr,AL HEALTH PERMITsa �y,�+ i�j '� p ,+ LIQUID WASTE Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District r ,F Business Name (DBA)I •P i R SII 1'S t:zfoC .M Add ress+• z Owner ,.' .. Address i 2 Firm Partners, Addresses and Telephone Numbers aBusiness Telephone No. >77Emergency Telephone Na Contractor Licence No. '" ``- } U -" 1 Title M Date{�' Z2 a — � - LApplicants Name (Print) f`�1 -:; Please check Applicable Category(1-7) and Fill in the Required Information •. „�y 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) For July 1, June 30, 19- Disposal Sites 4 Description(Make/Yr., Color) Serial No. CAL. License No. CAL. License Renewal No. r Capacity .Gal.,Weights& Measures No. Equipment Parking Address 2. ❑ PUMPER YARD "ti i Com. For July 1,—. June 30, 19 " No. of Vehicles Stored No. of Chemical Toilets Stored ' _ r 3. ❑ PERCOLATION TEST `N R.S. or R.C.E. NameR.S. or R.C.E.No. Test ocation � - � W �Test Date/Time.� 4. ?5-SANITATION PERMIT '. f+ts r"� I i4o use.., Job Add�r ss/Location ��-�� D1• �r� � � O ner 14A"C- Address VSEPTIC TANK ❑ CESSPOOL LEACHING FIELD 11 SEEPAGE•PIT-- ❑ PACKAGE PLANT C PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER 9 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 "` C Type Construction Disposal Site No. of Units Equipment Storage/Cleaning Locat*on(s) j: 6. ❑ PACKAGE TREATMENT PLANT For July 1, June 30, 19 Operator Name ( Where Certified Plant Location Plant Capacity No. Units Served' t 7. Cl LAUNDRY For July 1, -June 30, 19 ' n I llj SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. P ❑ DRY CLEANING, Chemicals Used/Amount/Mo. S mitisiss: 'ta" temployan e: .n t''IOmenwti6r4stiE': r,.r,'rr,� s ;::•4!<rC^Cri'?ni?�eSnlics+.r�rir-rte:"if:E"ti'V. 'i :' 9�r-„_�I"13n;�C;'h6'. ;Fi^;4Ti^.G:tSpET E+i,i �'0 :rP in sttCh mannan CS tG l?e'JL'::1wJ`:U�;;eL-i t,J'a`:.i'..ii'i"r'�3':.'Ci)'.iftP52l'rC:;idY'::df{'ailfiii�e� � '� Contractor's hirin t or sub-contrR «t1p sigrsat ire .unifies Lha follp•,roincg: "I certify that in the,perforinanee Uf'lhe work foY,wh'ch th'ls permit is issued,l shall J employ persons subject to workman's corT pensatlan laws_cf 0alifomi2�." t f 5 r. r I hereby certify that I ha prepared this application and that the wo will'be'done in accot'.dance with San Joaquin County t pp ;y ordinances, state laws,a' rules and regul ons of the Joa ui cal Hlth District. Y l 'APPLICANT'S SIGN TURE.X rq” ., CIIreS ;,LI FOR DEPARTMENT_ USE ONLY f •{ .Fe�-Is.Dues,M`ANNUA,L Y J! ❑ PER UNIT ❑ PER SITE ❑ EACH / ❑. January 1 &Received By January 31 ❑`July 1 &R@ceived,By July 31"i _._. :. p x r t BILLING REMITTANCE $ fl Ei AMOUNT -CHECKED" f • t-� lst.i• :BA$E.� EXPLANATION DATE ," DATE REMITTED - +'c_'A AMOUNT FEE t �� LESS + ) PRORATION PLUS PENALTY OTHER s OTHER IA r -r M11ieceived by _ Date Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALC-COPIES TO: ENVIRONMENTAL HEALTH-PERMITlSERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201r S f