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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 y <br /> Application is hereby made to carry on business in the jurisdictional.area of the San Joaquin Local Health Di trict <br /> Business Name (DBA) 12H .�1P1�1-1 �_�-,_ �• -AddressF® — <br /> z Owner s. -Address <br /> J Firm Partners, Addresses and Telephone Numbers ! <br /> a Business Telephone No. L�^rO� O Emergency Telephone No. + <br /> J= <br /> Contractor Licence No. <br /> L Applicants Name(Print) ��� y :_-� I S` Title .Date —1 a <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 - Disposal Sites: <br /> Description(Make/Yr., Color) I <br /> Serial No. - CAL. License No. ' 714 ? CAL. License Renewal NO.'19 <br /> +w.,.. ,..=•i_�. '� , P '�� ' � ��''�ts_...w' ` Y i O!`....:f e�.5l ..,c� `{ 7 ✓'i � ' <br /> Capacity Y Gal.,`Weights & Measures No:{ <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.G.E. Name t R.S. or R.C.E. No. i <br /> Test L cation 11 ' 'F-- Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location 2-17 t <br /> .- - <br /> O ner, n �s t Address-, <br /> I ❑ PACKAGE_'PLANT•. <br /> VSEPTiC TAW-0- CESSPOOL`a' Fl LEACHING FIELD. �SEEPAGE;PIT, <br /> y�PERMANENT ❑ TEMPORARY NEW f L.J ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19`"v" <br /> Type Construction DisposAl:�ite <br /> No. of Units Equipment Storage/Cleaning Location(s) ' <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June.30, 1 fi <br /> Operator Name }I i (_ 1 Where Certified - <br /> Plant Location 7 <br /> Plant Capacity/ �_ No. Units Served <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 /> Home owner orlicensed agent's signature certifiaodiefnllowing:"3 crrtifVtW in fhlf perfprrr41W(f the work forwhIch this permit is issued.Ishaltnot employ any person <br /> In FJch mannar as tQ became subject it)wo rkm an's 4mpensatiian lav,s of Ca faraia" . <br /> Contractor's hirinq or sub-contractingsagrt>,tuxe certiiieP !h4-fostowing: 1C8tti3y that in the parformam of the wrk for�rhich this permit is issued,I shall <br /> employ perstrns sub itet-to workman's eom3ensati6r taws of Califorrt a." <br /> I hereby certify that I hav reparedahis;application and at the work w' I be done in accordance with Sari Joaquin County <br /> ordinances, state laws, a rule and regurlati of the n oaquin Lo He District. f <br /> t : ! 1A' <br /> APPLICANT'S SIGNATUREX - ,f f <br /> 4V, b i <br /> fs i <br /> -- <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 3t ❑ PER SITE ❑ EACH ❑ January 1 8.Received By January 31 ❑ July 1 &Received By July 31 <br /> ) BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE , DATE REMITTED AMOUNT DUE O.AMOUNT <br /> �- � - �,•,.,,,-,-X�'.R,FEELESSPRORATIONPLUSPENALTY .r. <br /> 7 t { a <br /> OTHER ijis,. <br /> OTH1=R <br /> Received by Date Receipt No. - Permit No Issuance Date Wailed Delivered _ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA ELTON AVE.,P.O.B0STO ONA 95201 <br /> -3� pi� aP6)rD <br /> u <br />