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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Tranaterable, Revocable,'an l 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 /> rn Business Name (DBA)_1P1 21, S ` `' YAddresa� <br /> i Owner a Address s <br /> Firm Partners, Addresses and Tele hone Numbers <br /> IL <br /> Business Telephone No. Emergency Telephone.No. y <br /> Contractor Licence No. Z '� ray t <br /> . .. .y lS v r <br /> Applicants Name (Print) 9 Title y Dae 9:�� <br /> Please check Applicable Category (1. . and Fill in the R quired Information a S <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July I,-- June 30;°19.-::: Disposal Sites _- - ---' <br /> Description(Make/Yr", Color) <br /> Serial No. t T CAL. License No. CAL. License Renewal No. <br /> Capacity -' Gal. Weights& Measures�No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD a <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. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4.- .99 SANITATION PERMIT 41--•-- - - <br /> Job Address/Location <br /> Owner f ��' Address :a M <br /> ❑ SEPTICTANK-- CESSPOOL LEACHING FIELD 5rSEEPAGE PIT ❑ PACKAGE PLANT <br /> 13 PERMANENT j1❑ TEMPORARY F-1 NEW REPAIR ❑ OTHER <br /> 5. 13 CHEMICAL TOILETS For July 1, -June-30, 19 ;L <br /> Type Construction l ` ' Disposal Site P <br /> No. of Units f Equlpment,Starage/Cleaning Location(s) <br /> -6. 11 PACKAGE TREATMENT PLANT `For July'1, June 30, 19 <br /> Operator Name Where Certified <br /> i <br /> Plant Location <br /> Plant Capacity -4" _ r No. Units Served <br /> 7. ❑ LAUNDRY_ For July 1, -June 30, 19- <br /> SIZE: C1 Less Than 1,000 Sq. Ft.,: ❑ More Than 1,000 Sq-Ft. � <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Homo ownardr licensed agent's signatrxe ter EifieS theftlltowlm9:1 certify that in the performance of the work for which this permit is issued,l shalt rwt emptvyarry person <br /> I <br /> - in such manner as t©become 5ulljeet to woTklnaii s ct�tzpansatiorl aN°5 of Catiiorr�ir?." ' <br /> Contractors hiring or sub-contmeting signature rfirWies the loitavAIW "i certify that in the performance of the work for which this permit is issued,I shall <br /> empfoy Persons subject to workman's cumpensation taws of California:" - <br /> r <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 regulat ns of the San Joaquin Local Health District" - <br /> APPLICANT'S SIGNATUREX # <br /> FOR DEPARTMENT-USE ONLY >.. <br /> �- Fee IS Due: ❑ ANNUALLY r❑ PER UNIT' ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> t REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> i g DATE r DATE REMITTED C AMOUNT <br /> U t <br /> FEE 'S f <br /> LESS ,;k� :, s.t-.,� w. - •. ,",'`' �' f, =` <br /> PRORATION - ' _ • <br /> PLUS <br /> PENALTY <br /> OTHER <br /> QTIIER <br /> Received by Date Receipt No; Permit No. s uance Date detl'" Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES '1601 E.KAZELTON AVE., o■2009 STOCKTON,CA 95201 <br />