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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheAppucauon. <br /> APPLICATION <br /> (For Non-Transferable;Revocable;and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby mad to o b si ess in the jurisdictional area of th an J in Ll FJeaitthh District. <br /> rn Business ame DBA) Address� � L , <br /> z Owner <br /> �-- Address <br /> j Firm Partners, Addresses an a hone umbers <br /> a Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> CiAliL,APpllants Nair(Pr t)Yw` Y to <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> r1•..❑._PUMPER VEHICLE PERMITf,REGISTRATION (FOR EACH VEHICLE) i <br /> .For July 1, June 30,119= r Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. �-� `— r+ -rCAL'.License Renewal No. <br /> Gah Weights &-Measures-N07 <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30,19 <br /> No. of Vehicles Stored <br /> No..of Chemical Toilets Stored <br /> 3. PERCOLATION TEST <br /> R.S or R.C.E. NameR.S.or R.C.E. No. <br /> Test Date/Time- <br /> I TeA�--]Location I ` <br /> 4. l SANITATION PERMIT <br /> ~ L�� <br /> Jo Add /Location <br /> OwnerTy - Addres `0 <br /> nPERMANENT <br /> EP71C TANK CESSPOOL EACHING FIELD SEEPAGE PIT ❑ PACKAGEPLANT <br /> ❑ TEMPORARY W © REPAIR OTHER t <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> S y <br /> No. of Units Equipment Storage/Cleaning Locations) t s.: <br /> k <br /> 6._ PACKAGE TREATMENT PLANT For July 1, -June 30, 19.; <br /> Epp rotor Name Where Certified 4 <br /> t <br /> Pak r.t Location <br /> Mat Capacity No. Units Served t <br /> 7. El LAUNDRY For July 1, -June 30, �9 {.• �. 1 <br /> sSIZJ: ❑ Less Than 1,0&0,,Sc(Ft -�.❑ 11+1or`e Thi"11000 Sq. Ft. <br /> 11 DRY CLEANING,Chemicals Used/Amount/Mo. <br /> - E1iLmeownerorlinense agent's signature corcifloslhefollowing;"Icert!t,i*a',inthe fierurmanceaftheworkfoi,which this permit isissuetf.lshall not employ any perso�rr <br /> j inilgucti marwor as to bec me subject to workman's compensation laws of Ca'forail" <br /> v ntreet or's Airing ort.sub-carnaeaRg-s'+goature-certifies-themfoltowing. I cert4y-tial in the performance of the work for which this Permit is issued.I shIall <br /> -o play persons subject t)workman's compensation laws of California.' r n p <br /> F p� . rte' � f.��s r <br /> I hereby certifya ve prepare his application d that;the work Wi11"6e done in accordance with San Joaquin County <br /> ordinances, state laws, n ul s and r gut f t e San Joa in Local Health District. <br /> _AP <br /> ICANT'S SIGNATOR (( <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH El January 1 &Received By January 31 ❑ July 1 &Received REMIT 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE {i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY r 3 <br /> OTHER <br /> . OTHER <br /> y i ate - Receipt No. I Permit'.o j Issuance Date Mailed Delivered <br /> Received by _- <br /> APPLICANT 'RETURN ALL-COPIEs�TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES t 601 F,HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA:95201 <br />