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Applications Will Be Processed When Submitted Properly Completed. Be sure <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRIJNMENTAL'•,HEALTH PERMIT f <br /> "'.. w LIQUID WASTE 4 1 <br /> Application is herebymade to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ' N Business Name (DBA D9P _ i Ing Address <br /> aOwner +ZrOI li--- Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> $ <br /> Business Telephone No. w Emergency Telephone No. <br /> a - ) <br /> A Contractor Licence No. Date <br /> �Applicants Name (Print) Title P- <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> s 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sitesh = a <br /> Description(Make/Yr., Color) <br /> Serial No. No. CAL. License Renewal No. <br /> CAL. License <br /> f" Gal., Weights &Measures No. <br /> Capacity= � � � � k N. v%r- � f <br /> Equipment Parking <br /> T <br /> 2. ❑ PUMPER YARD Y�x <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored y ,, b M u <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E.Name <br /> Test Location Test Date/Time <br /> 4. "❑ SANITATION PERMIT , <br /> Job Address/Loco i'o 2554 -Elm. Stre6t Farz ten _ <br /> Owner-$9Mfi!$B A1@ F Address tE3` � IlL�II~� �.. r <br /> g ❑ PACKAGE PLANT tf <br /> i im SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ( -" <br /> ❑ REPAIR ❑ OTHER <br /> I PERMANENT 11TEMPORARY NEW s <br /> 5. ❑.(CHEMICAL TOILETS For July 1,-June 30, 19 r f <br /> Type Construction # Disposal Site <br /> t <br /> No. oftUnits Equipment Storage/Cleaning Location"(s} <br /> R 6. []'PACKAGE TREATMENT PLANT For July 1,-Jun 3 19 k <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> " No.Unill Served. ' <br /> Plant Capacity 1 <br /> 7. ❑ILAUNDRY For July 1, -June 30, 19 - <br /> ❑ More Than 1,0100 Sq. Ft " <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,' _ _ <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - <br /> f <br /> }Some owner ertieeesadageni'i=Rignr�tureCf.,.!r�csth�.6t+ow €orfliytt+ztlnThepericrmanceeT,theworfiforwhiafltspermitisissued,fshagnotcmyttayany person <br /> in such manner as to becontc of C$Mom- or <br /> Contractor's hiring nr suh-cortttaeting sr�nat:>re canities th® toltmnrn9: "1 certify that in ttte"performance of the work for wf,iall this permit is issued,I shall ` <br /> employ persons Subject to workman's compensation taws of Caiiforhia." + <br /> a, r , <br /> Hereby certify that I have prepared this application'and that the work�willl e done in accordance with San Joaquin County <br /> ordinances, state laws, and les and regul ions of-the San J quin kcal health District. <br /> - e • <br /> rte• a "r" M^' <br /> APPLICANT'S SIGNATURE X ( 1 <br /> . y,:'Y s "I'' �t• f: +" -'t i "� . . OR+DEPARTMENT USE ONLY t f t . <br /> [. • ti <br /> Fee IS Due: 13 ANNUALLY__ 1❑PER'UNIT - d PER SITE '.❑ EACH. ❑ January 1&Received By January 31' ` ❑•July 1 &Received By July 31 <br /> REMIT <br /> g •- s -BILLING •REMITTANCE • $�: AMOUNT OUE CHECKED <br /> §BASE- t` -�EXPLANATION 3'< DATE i DATE t REMITTED AMOUNT <br /> " FEE r �. 'MSS �»( fir:. as 3- ; r .� ��} Z°} �, � r •�� . <br /> LESS <br /> PRORATION 7 C <br /> 's`.V 1 .,,;.� . r.,,r.d�`.=.3.3 y �. �%- _ '''y'/�•� _�+`.� / -. <br /> F: , <br /> PENALTY -' � - v _ � `,� 4 , <br /> OTHER <br /> OTHER t- a`s a Y".x} x�� ,.•-' ' "�.4. _ . <br /> Received by Date Receipt No. Permit No. issuance 1e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTO -,P.O.Box 2009 STOCKTON,CA 95201 <br />