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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 /> /L ( ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati hereby madeto carry on siness in the j dictional area of the Joaqui Cal a Distric <br /> y Business Name (DBA) � iF.�.� o� T Address <br /> i Owner Address <br /> C <br /> u Firm Partners, Addresses and le hone Numbers `- <br /> aBusiness Telephone No. 'S �' Emergency Telephone No. <br /> Contractor Licence No. oe <br /> �Applicants Name (Print) _340_2? <br /> Title Date <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 j <br /> Description(Make/Y-[,,Golorr y' <br /> Serial No. C*L. License No. CAL. Liceneedliklewal No. <br /> Capacity Gal., Weights&Measures No. zY <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD !s hl <br /> For July 1, Jun€911.,1.9 ' - <br /> _ <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 Datg/Time i <br /> 4. ❑ SANI ATION PERMIT 7� -y <br /> Job Addre s/ oc tion J t <br /> Owner l Address � <br /> SEPTIC TANK ❑ CESSPOOL 91-r ACHING FIECQ, E,/t' <br /> EEPAGIT0-PACKAGE-AL+4NT <br /> S -•,.- <br /> U11,-PERMANENT ❑ TEMPORARY 9;'1TEWh REPAIR f ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,;Jung 30, 19 <br /> Type Construction , Disposal Site a <br /> No. of Units Equlpenent,ptorage/Cleafng Lo%ation(s) �- <br /> 6. ❑ PACKAGE TREATMENT PLANT For Jul r 1,f�tlne 30, 19--x" 'v y <br /> Operator Name ' Where Certified <br /> Plant Location ' <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 u <br /> SIZE: ❑ Less Than 1,000 Sq. Ft,, ❑ More Than 1,000 Sq."Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> NORM oweerorBcennd signstu!rsQsrfllfeslh**Ma vhq--tCerti�ewlrtMe <br /> sgent•s r t $rmsrtcooftlleweric for wAichfltt3permitis Issued,i Shah notemployany persa► <br /> in such manner as to t18CpInE s�JtgeGt to workfiatt's cgn►p>:ns 18YrS 4f f:�ifOrni4," <br /> the Conerae+dr's or orb cent. <br /> employ perselns s�ub*1 to workman's pe+lsa n a itmnia : ' aN#ify h pbiOflRaap of the walk t11r wrhlsh this'permit is issued,t shall 'I <br /> I hereby certify that I have pr a his application an work will be done in,accordance with San Joaquin County <br /> ordinances,state laws, and r d regulations of Jo C ealth District. <br /> I, <br /> APPLICANT'S SIGNATURE <br /> FOR,bEPARTMENT USE ONLY <br /> t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑JEWC ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING ¢REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> D41TE DATE REMITTED AMOUNT <br /> FEE <br /> LESS l <br /> PRORATION 1 ,' <br /> PLUS C <br /> PENALTY <br /> OTHER f <br /> OTHER <br /> Received by Date Receipt No. Permit No. I Issu nce Da Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON O.Box 2009 STOCKTON,CA 95201 <br />