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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) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin-Local Health District <br /> Business Name (DBA) T� a•F4�E1S__f� �C71J5yZ'L?G . Address T �5zor <br /> aOwner Address { <br /> J Firm Partners,Addresses and Telephone Numbers <br /> 0. Business Telephone No. -SW6Q-7 Emergency Telephone No. <br /> -J Contractor Licence No. Z , <br /> Applicants Name (Print} ��+dr.�l_ y g• �1 �_. Title��ih4�4�.a.EQ. Date -7—1 5—�- <br /> Please check Applicable Category 0-7)and Fill in the Required Information jo <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1; June 30, 18 = ' Disposal Sites <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 ;A �1 <br /> 2. ❑ PUMPER YARD{ I <br /> For July 1, June 30, 19 <br /> y � � <br /> No. of Vehicles St6red '`' ' _ <br /> _ - :. p.w-e•w .t- r ... ars" V -s��r <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/Time— <br /> 4. SANITATION PERMIT 1 _ <br /> Job Address/Location © <br /> Owner 1 Address <br /> SEPTIC TANK ❑ CESSPOOL )KLEACHING FIELD X SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW X REPAIR ❑ OTHER <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 /> _ yr <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> ,.SIZE: ❑ Less Than 1,000 Sq. Ft.,t ❑ More Than 1,000 Sq. Ft. n <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Homo ownerorlteensedagent's lsignature certifies thefoltowr►g:"I certify that in the performarmeofthe work for which this pemitisissued,isha temployanyperson <br /> in such manner as to becomesubim to Workman's Cnmpensatior,laws of Califorma ' <br /> r - Contractor's hiring or sutr-eontractirr signahFre rarufie,c tho folfaw rig: -'!cetih'f h:!t iii the pelt,mxmc:4f the 1Jofk for which this Itis issued,I shall <br /> employ persons subject to worknlari 5 coma persatiwi lairs u. <br /> I hereby certify that I h prepared this application an that the wor will be done in accordance with San Joaquin-County <br /> ordinances, state n ru es and reg ions of n Joaqu' al Health District. <br /> APPLICANT'S SIGNATUR/I.awls <br /> y n - �Y� .h <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 /> REMIT <br /> `a BILLING REMITTANCE $ <br /> BASE EXPLANATION ` AMOUCHECKED , <br /> DATE DATE <br /> •�REMITTED - NT DUE- AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ' _ <br /> PLUS i t. <br /> PENALTY <br /> OTHER. E <br /> OTHER 1 <br /> " Received by Date Receipt No Permit No Issuance ate Mailed Delivered <br /> f APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,GA 95201 <br /> �1 t <br />