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hen Submitted properlyCompleted. He bure 1001911 1... <br /> Applications Will Be Processed W <br /> APPLICATION <br /> j (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH. -PERMIT <br /> LIQUID WASTE <br /> Appl icaIt an is hereby ma a to car on busine In the ju isdictional area of the San Joaquin Local Health Distric) <br /> Address_ d �' <br /> s w Business Name (DBA) T <br /> { i Owner Address <br /> 4\1[ a { <br /> a Firm Partners, Addresses an Tele hone Number Emergency Telephone No. <br /> ' 0. Business Telephone No: •� z <br /> I 1 Contractor Licence No. ate..-- <br /> r Title ` <br /> LApplicants„Namel(Pr+rit) <br /> Piease.check Applicable Category(1-7)and Fill In.the Required Information <br /> j <br /> 1 1❑ PUMP.EWVEHICLE PERMIT-•FIEGISTRATION (FOR EACH VEHICLE) <br /> w �! : �?. `-, --. --Disposal Sites - <br /> For July 1; - June 30, 19 - .� <br /> L Description(Make/Yr.,Color) ' ' CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity 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 /> 1-0-PERCOLATION-TEST�-- R.S. or R.C.E.Na - <br /> R.S.1or R.C.E.Name �1 -••'d <br /> Test Date/Ti <br /> Testi Location me <br /> 4. SANITATION PER T l <br /> JobiAddrgss/Location <br /> Ow+�er Address <br /> ❑ PACKAGE PLANT 1 <br /> ❑ SEPTIC TANK, P-CESSPOOLLEACHING F1ELp EEPAGE PIT ❑ OTHER <br /> ❑ PERMANENT ❑ TEMPORARY f NEW 4} IREPAIR y <br /> 5. CHEMICAL TOILETS For July 1,riJune 30,-19 ) <br /> I Type Construction Disposal Site I i Aj <br /> No.'of Units Equipment Storage/Cleaning Location(s) <br /> B, 0 PACKAGE TREATMENT PLANT For July 1, June 30, 19 Where Certified I <br /> Operator Name f ) <br /> Plant Location _ <br /> ! Plarit Capacity t No. Units Served a y <br /> 7, LAUNDRY r For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 13More Than 1,000 Sq. Ft. <br /> ❑ 17RY CLEANING, Chemicals Used/Amount/Mo.�-( <br /> Horne owner orllranzcdnr mnf's'!'q 1Rf1tre rC!tSf!n�th(fC1�C4L?nr�:"I csr;ifv ttiat in t;c�arfor ra acr of the�vorkfc,r.h ch ih3;permitis issued,I shall not employ anyperserT <br /> �r!suchmanr". ,::3 �`.�E?C.^.iP-Slit."2rtlii �.,� 3 <br /> Corrtrae2nr'r. e r,�- ;o IMOS t:10 �aElornrii.y: . i certify twat in the perfo bianco of 1tle 1vu k for which this permit is issted,l shall <br /> tniploy persolls Subict;t to 146Fl.irlall'5 ColnPl lE" I <br /> 41 1311'5 ei <br /> I here t l have eed t j's ap 'cation.andAhat-the-work wi11 be done in accordance with San Joaquin County {` <br /> e: JoaquinLocal Health Districordinances, state laws und. y <br /> APPLICANT'S SIGNAT <br /> - • - . - �� � � - .� Com..: �'�. - - � <br /> i - <br /> 1 ! I FOR DEPARTMENT-USE ONLY m r <br /> i <br /> � PER UNIT � ;❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received_By July 31 <br /> Fee IS ti?Ue: ❑ ANNUALLY ❑ - - �-•"'"'liEM17 <br /> ?BIDING REMITTANCE AMOUNT DUE CHECKED <br /> -- _ IBAS� EXPLANATION DATE - REMITTED - AMOUNT <br /> -- FEE- U /- <br /> LESS °* r <br /> - <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> T, <br /> OTHER <br /> ' x <br /> Date - .Receipt No; Permit No, <br /> Issuanc late Mailed Delivered <br /> Received by - 1601 E.HAZELT E.,P.O.Bo=2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITlSERVICESV <br />