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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGi <br /> ' ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on bust ess in the jurisdictional area of the San Joaquin Local Health District : <br /> H Business Name (DBA) 09 I- Address A 0• ex f ��5�� ��l�ey <br /> a Owner _ - L _ry Address . <br /> �. <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No:. "V.66` 94 0. 7 Emergency Telephone No. <br /> Contractor Licence No. <br /> a Applicants Name (Print) L �tR�q,�kello'rimfl',n TitleDaeL Please check Applicable Category (1-7)andFill in the <br /> 1. ❑ PUMPER VEHICLE PERMIT RECaISTRATION (FOR EACH VEHICLE) <br /> For July 1,—June•30, 19 -.Disposal Sites - - - — <br /> Description(Make/Yr., Colo_r) _ <br /> Serial No. r CAL. License No. ;. CAL. Licen_se,Renewal No. <br /> Capacity' "' -_ -Gal., Weights&Measures No. <br /> l Equipment Parking Address _ <br /> 2. ❑ PUMPER YARD . ,: �w <br /> I. For July 1, June 30, 19 rt - <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E.Name R.S.or R.C.E. No. <br /> Test Location Test Date/TimetIc- <br /> 4. X SANITATION PERMIT <br /> Job Address/Location Z3�� a a <br /> Owner ► ' �-� "rlc9r�i rm' 3L Address ,, A�11 <br /> 11 SEPTIC TANK 11 CESSPOOL P LEACHING FIELD 91 SEEPAGETPIT 1:1 PACKAGE PLANT V' <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR- ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30,,19_ .. .. <br /> Type Construction A �--�� Disposal Site �- •_ <br /> No. of Units - "Equipment Storage/Cleaning'Location(s) i <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 t <br /> Operator Name t ; ' - - - Where Certified r <br /> Plant Location t i <br /> Plant Capacity ' No. Units Served ; <br /> e ( a <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 /> 1'tnme"nor orlicensedagent'ssignature certifies the following;"I cerlifythatintf eperformanceof the work farwhichthispertrtitis issued,l'shall not employ any person <br /> i.l;,vch manner as to become subject to vvorkmaii s compensation laws of California." , , <br /> Contractor's hiring or aub-contree:ing signature certifies the f000vortg; 1 certify that in the performance of the work for which this llermii is issued,I shall <br /> employ persons subject to work,1,ao'S compensation laws of Cabiamla." <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> -ordinances, state laws, and rules and regulations of the San Joaquin I- ealth trict. <br /> ,APPLICANT'S SIGNATURE'X r <br /> w -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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE ,DATE REMITTED AMOUNT DUE CHECKED <br /> C AMOUNT <br /> FEE : ,+. �Y- .w ..�c - ++i �y,• � ] i <br /> LESS t� # <br /> PRORATION - - <br /> PLUS <br /> PENALTY <br /> OTHER S4g <br /> ' r <br /> OTHER <br /> 6-17v C <br /> 1 t—RReceived by pate jv.__.�.Receipl No Permit No rh-a .V Israncp Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: `ENVIRONMENTAL HEALTH PERMI ISERYICES - —1601 E.HAZEL'TON AVE,P.D.Box 2009 STOCKTON,CA 95201 <br />