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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 h febyade to}c�arry business in the jurisdictional area of the San.Joa I cal Health District <br /> N Business Name (DBA f Address Gh Z�N f .Z <br /> aOwner dress .�6cs f ; /,ZM ,ec.,.�� <br /> J Firm Partners, Addresses and Telephone Numbers a <br /> 0. Business Telephone No. -� ��`� Emergency Telephone Na. �' •�" �� <br /> Contractor Licence No. - J7,Y- 7-54 <br /> Applicants Name (Print) Title t rz zV eo-, Date -*2 7 —92- <br /> Please <br /> 92Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ` <br /> For July'l, June 30, 19 Disposal Sites i <br /> Description(Make/Yr.,Color) <br /> Serial No. - T CAL. License No.r CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. k <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1,' --- June 30, 19 t <br /> No. of Vehicles Stored F . <br /> No. of Chemical Toilets Stored x <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:-'0 SANITATION PERMIT--t <br /> �' �/Y�/i C �eC , <br /> Job Address/Location � O <br /> �l <br /> Owner Z!70 eff ,�AA 1 rek + Address .�,'4'A 066 <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD, 11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ®-.NEW ❑ REPAIR i❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 I F. <br /> Type Construction X, Disposal Site .. <br /> ,No, of Units f Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For- 4 I <br /> July 1, -June 30 19 -{ <br /> , <br /> Operator Name J Where Certified <br /> , <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., ❑ More Than 1,000 Sq.'Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> ftomeownerorticensedapmiessignaturocartifiesdrefotlowing;"lcartifytha11intheperformanceoftheworkforwtlichtWpermit•iisissued,tshatliw employanyperson <br /> in such manner OS to become subject to workamn's a mpemalion laws of C 1lprriiE.' I s I t i <br /> Cantractor's hiring or sub-comraotbW signature ceril tM toftwing A certi:y tl4aailittrre pertormince'uf ihework tar vihieh:his oefml t is issued,I shall <br /> employ persons sub*[to workman's compensation laws of Calitarrlia:' <br /> y <br /> I hereby certify that I have prepared this application and that they(ork will be done in accordance with San Joaquin County <br /> ' ordinances, state laws, and rules anregulation's of the 5 n Joaqui Local Dist r t. i 1. <br /> APPLICANT'S SIGNATURE X <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 /> .' *.—VA REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE. _,, DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> t zPLUS <br /> PENALTY <br /> OTHER r <br /> OTHER <br /> 123a <br /> Recei ed b l0ale Receipt No. Permit No Issu ate Mailed Delivered <br /> APPLIC T—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA ELTO .,P.O.Box 2009 STOCKTON,CA 95201 <br />