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i Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable;Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of theSanJoaquin Local Health District t.. <br /> yBusiness Name (DBA) Ad ss <br /> z OwnerAddress <br /> a z_ <br /> J Firm Partners, Addresses"Telee NumbersaBusiness Telephone No. ' `sr�� Emergency Telephone NoContractor Licence No. <br /> Applicants Name (Print) J _ Title - <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 V Disposal-Sites "X <br /> Description(Make/Yr., Color) <br /> Serial No, CAL, License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address , <br /> i <br /> 2. ❑ PUMPER YARD ,..• �'r � <br /> For July 1, June 30 19 <br /> No. of Vehicles Stored K <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 /> f: - <br /> Test Location r'` Test Date/Time ±. <br /> 4.' 0 SANITATION PERMIT` <br /> Job Address/Location r✓ � S �� �' �.1 <br /> Owner �_ h� ,_Add;e5s W <br /> ❑ SEPTIC`TANK "❑ CESSPOOL ❑ LEACHING,-DIEL-D= ❑ SEEPAGE PIT PACKAGE PLANT 5 <br /> ❑ PERMANENT ❑ TEMPORARY ❑, EWA,. ❑ REPAIR �TH~ER I <br /> 5. ❑ CHEMICAL TOILETS 'For July I-;�June 30, 19 k �w <br /> Type Construction g 4 f. - s Disposal Site <br /> No. of Units ` ` Equipment.Storage/Cleaning Location(s) f ,xi <br /> 6. ❑ PACKAGE TREATMENT PLANT Foq 1 June 30,,19 i <br /> Operator Name �" <br /> V_ Where Certified <br /> a ' <br /> Plant Location <br /> Plant Capacity = _ ! No. Units Served!x� <br /> 7. 'El—LAUNDRY For July 1, -June 30, <br /> ,ft ' <br /> SIZE: ❑`Less Than 1,000 Sq. Ft., t0 More.Than0,000 Sq. Ft.13 " <br /> DRY CLEAN ING,zChemicals Used/,Amount/Mo.--� z s <br /> Homeowner..orlitensad�grnt'ssig�a u.ecpne3ieslteofaElor�eRrJ""rertsti'�;ha i eperfu; ants ffti wort for ti?hichtlzisrermitisissued.isE�allr;oternplcyzmype!scn <br /> in sitch mannnt as to become svbiact to workman"$compeasatlon,a,.vs tlf C7liln?a E .� <br /> Contracto 's-hia" or subcontracting signa-zure conifieu tiro fotlowina: •`iCertify the in&D pertcnrianc2 n1 the work for which this pertnst ir:is,ued,i sha11 <br /> employ persons subject toNarkmaii's compensation laws of Catitornia" j <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 rules and regulatir of 115 Sah J.Ct5win Local alth D' trict .! <br /> e <br /> APPLICANT'S SIGNATURE X77> <br /> .� ! >� <br /> t � z <br /> FOR DEPARTMENT USE ONLY ' <br /> Fee Is Due: ❑ ANNUA'ELY-_ ❑ PER UNIT ❑ PER SITE EACH ❑ January 1 8 Received By January 31 © July 1 &Received By July 31 <br /> .--.,,. REMIT <br /> BASE T FXPL-ANATIX ONS BILLING4I. REMITTANCE $ AMOUNT DUE CHECKED <br /> Q{' DATES DATE REMITTED — 4 AMOUNT <br /> FEE <br /> LESS a,'_.-+ <br /> PRORATION <br /> s <br /> PLUS r'"•- � • <br /> PENALTY' <br /> 10 <br /> OTHER <br /> OTHER <br /> Received by ate Receipt NO: - Permit No. Issuance Date Mailed Delivered' <br /> APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES '"16ot E.HAZELTON AVE.,P.O.Bok 2Do9 -STOCKTON;pA-95R01 <br /> fV__ill�T,'}I <br />