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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 /> l LIQUID WASTE <br /> ApplicatioJn�is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District,. <br /> w Business Name (DBA) / ETT bL �/}� �/¢IC�SEi1/' _'Address ✓�sc�/ f�iStCJ�`/�iLiO��. !� '- �l .�yuJe� <br /> z Ownerr Address - <br /> a <br /> J Firm Partners, Addresse n�T`elephone Numbers r. <br /> C6 <br /> Business Telephone N l�l.�� ` .3 ��. �- J Emergency Telephone No. . <br /> Contractor Licence No. . > -- <br /> Applicants Name (Print) Y ��T J¢K�SE� Title w _ Date:- <br /> Please <br /> ate.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 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewai No. <br /> Capacity Gal., Weights & Measures No. f' <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. ❑ 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. A SANITATION PERMIT <br /> 'Job Address/Location D� WA4,W )>D _ <br /> Owner PE"T� bAddress <br /> SEPTIC TANK. ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER ' <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 T <br /> s _ <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 t <br /> Operator Name ' t Where Certified <br /> Plant Location r_ <br /> Plant Capacity N9)_"its Served f <br /> 7. ❑ LAUNDRY For July 1,,-June 30, 19 F - Y <br /> SIZE, 'El Less Than 1,000 Sq. Ft ❑ More Than�,000 Sq..Ft. <br /> DRY CLEANING, Chemicals Used/Amount/Mo. 4 <br /> �If <br /> Hama4>wn+e.ort;cnni>rdegeMt'sp(gtt rrncerti#Mxtilrfolfowtstg:"tCerfliythatint}aeptrFershanCetftlhaw+xPkiDrwhicltlhispei'fnitisissued.fsha:fn6lemploy any perssn <br /> in WCh ttlaMr d5 to betomesOectfe workthan's comptmsation laws of Cali€omia." ,_ ;x <br /> C93ir"W is hh"_ ,nr "-rn+n.�fin9 l�gn Mro-c,�ifien Me fWtow:na: t csit iQtlll the f leftmaftce of the work for which this permit is issued..1 shall <br /> efnploy pars S subl 10 wnrkm:ms commmsatian laws oft Mifcrnia.'', ; <br /> I hereby certify that I have prepared this application and�tha the ork will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r les and regulations o e SarJoaquin Local Health District. <br /> APPLICANT'S SIGNATURE X . <br /> - - i - • - - 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 /> y <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DU CHECKED <br /> DATE - PATE - - REMITTED - ''AMOUNT <br /> FEE. �0 - ^ - (4 J O s <br /> LESS "_ <br /> PRORATION i QOIJ�- GVl e CoA lvEY6. 2n'Q <br /> PLus 0 s�2 �r`t` Y �'111v�P {�1'�` r . rc LL �i` Vk� D� P1 <br /> PENALTY h/ 1f !! q f� /' 1]A -,r <br /> �(,t.1'l- ,� T -iv C C9i6` /UV• �JII�IT -�G�'1.VPa Tim �EOE•-f !4 <br /> QrJ-efltec Q / io/!k\ k�--40e- !1, [a /'/r His [rfx <br /> OTHER } 1'�{h 4 h L� )r�c <br /> Received b t <br /> DatA .Receipt N6 Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES�" 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 05201 <br />