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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 �)r �~ <br /> Application is hereby made toi,car on business in the jurisdictional area of the San Joaquin Local Health District , <br /> rn Business Name (DBA) Rgyz/zis&-i JV ry S Address O Y <br /> z Owner Address4 d_ I <br /> J Firm Partners, Addresses and Telephone Numbers 4; _ <br /> CL Business Telephone No. Emergency Telephone.No- <br /> Yea°. .. <br /> Contractor Licence No. <br /> Applicants Name (Print) /he _ ccf/ Title s" Date ADZ'/-8-2 - <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 June 30, 19 - Disposal Sites <br /> Description(Make/Yr.,Color) ^ <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> r <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 /> 3. 0 PERCOLATION TEST Y I <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. J@ SANITATION PERMIT> / y� <br />' Job Address/ cation_ /tL 0 A /✓e�s,rr ^� �1 <br /> Owner ✓�`_^_`t"'� �� 4 Address <br /> SEPTIC TANK ❑ CESSPOOLi Pr LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT ._. <br /> P1 PERMANENT ❑ TEMPORARYNEW ❑ REPAIR ❑ OT <br /> 5. ❑ CHEMICAL TOILETS For July 1,;June 30, 19 Y 0.�� % (qo' LL, �- <br /> / 6— <br /> Type Construction - . Disposal Site _ <br /> No. of Units Equipment Storage/Cleaning Location(s) h <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 } C <br /> ry <br /> Operator Name Where Certified' <br /> Plant Location I <br /> Plant Capacity No. Units Served l <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 v <br /> SIZE: ❑ Less Than 1,000 Sq. Ft-, ❑ More Than 1,000 Sq.'Ft, r r <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo` R y <br /> Homeowner air H;-onsedP.pant'st3enaur3cErtti9r.stbesfollowing:"Icnrtiti that In?r.I�perigrr�lanceafthewcikfirr�hiC#1thispermitisissued,ishall not employ any person <br /> in stlCtl mar;lEr as to besor:te b;Cc=t to wrrk r:a ...;,m�ensatielr,1:,4 r ii rni <br /> COtttrdC#Cr`s h7riztq or s! -C �iit i':R� v^:i:r' r rtii e.';'; 1�i!o �� _ I i;3lliy iS�t i( t:`;#'�cCiO.'iT u1:= ^i iFIH LVCI I:fdf 1I11Ch i14i5 perf'it iS i5S I@�,I Stall <br /> employ persons stlhj�ci t0'. PiUu,1:,5 i7i...,_utiuli la,,s Gt uuL. .ai;.. <br />' I hereby certify that I have prepared this application and that the work will be done it accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations the San Joaquin Local Health District. i <br /> s <br /> APPLICANT'S SIGNATURE X <br /> a � r ;o <br /> DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ,❑ EACH ❑ January;t &Received By January 31 ❑ July t &Received By July 31 <br /> r I - -,t — REMIT <br /> BASE EXPLANATION <br /> BILLING REMITTANCE i $ AMOUNT DUE CHECKED <br /> -�...� ;y,. <br /> :DATE, DATE, ,p ,REMITTED AMOUNT <br /> FEE <br /> LESS sfp �I <br /> } PRORATION <br /> s PLUS ! <br /> PENALTY . r <br /> OTHER <br /> OTHER <br /> - x <br /> x> 14 b� <br /> ` Received by Date Receipt No. Permit No. I issuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTo E.,P.O.Box 2009 STOCKTON,CA 95201 <br />