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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> _ APPLICATION <br /> (For Non-TransteFable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatljion is hereby made I carryon bust sin the}urfsdictional area of thVgoa6uin Local Health District <br /> y Business Name (DBA) 1�Mlftk �K��C� Address y n ; <br /> aOwner Address I <br /> r2 Firm Partners, Addresses an T leph Nrliers <br /> a Business Telephone No. Emergency Telephone No. <br /> I <br /> Contractor Licence No. : F <br /> "` \ Title to <br /> L Appli ants Name(Print} - i <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1:( ❑-PUMPJER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) t� <br /> For J ly 1,It June 30,119' S`� f Disposal Sites <br /> Description(Make/Yr., Color) , <br /> Serial No. CAL. License No,''�; !-A iCAL. License Renewal No. i <br /> Capacity Gal�-,-Weights-&Measures-No. <br /> Equipment Parking Address i <br /> 2. ElPUMPER YARD 1 g <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3.' ❑ PERCOLATION CTEST - <br /> R.S. or R.C.E. Name W R.S. or R.C.E.No. <br /> /Ti <br /> Test Date/Time <br /> �` ~ <br /> Test Location -� <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner °� t Address 5 <br /> ❑ SEPTIC TANK d CESSPOOL C3 LEACHING FIELD EEPAGE,PIT', 1:1PACKAGE PLANT <br /> El PERMANENT TEMPORARY ❑ NEW EPAIR ❑ OTHER I <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 1 <br /> Type Construction Disposal Site•� _ _ ^ ' <br /> No. of Units I' Egdipmerit Sto ge/Cleaning Locations) <br /> 6. 11PACKAGE TREATMENT PLANT For July 1, -June 30, 19 k <br /> Operator Name iit Where Certified <br /> Plant Location S l <br /> Plant Capacity No. Units Served <br /> i <br /> 7. ❑ LAUNDRY For�July 1, -June.30, 19 <br /> SIZE: El Less Than!1,006 Sq. Ft., 13 More Than 1,000 Sq. Ft.' <br /> 11 DRY CLEANING, Chemicals Used/Amount/Mo. c _ ,, <br /> I�omo owner o en ssignatureof if©�vi•sg '9 ccrtif !), _ nlr:,ar "ich this permit is lssuEd 1i 511all not employ any perw <br /> lir, seda cni'Lcer2ifi sih ? <br /> in such man`sser las to become:subject to workmanca.I Pe;rsaiieli?aws:oi <br /> Contractor:s.:hiring at sub-contracting signature'certirles tti, da3lorri%: I ;tki periorr'%mc-of':f;�4Y 1r for k'I11Ch Sltf> permit is i55S1e{3,I shall <br /> employ persons subject to workman'scompersatio;l faws of California" <br /> I t1,11'6e <br /> � ! <br /> I hereby,cert) at I have prepar this applic 'on a d-ha the work 1111 be done,in accordance with-San—Joaquin County <br /> ordinane ," a la nd es ions the S J 4 .� LocalHealtfi District' <br /> APPLICANT'S SIGNATURE X <br /> ' FOR DEPARTMENT USE ONLY <br /> _ Fee Is Due: 11ANNUALLY ❑ PER UNIT ElPER SITE /E] EACH ElJan 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT' <br /> ATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLAN <br /> A .°' DATE DATE REMITTED AMOUNT: <br /> �' � s.,,.��!-�..-. ...�r,-Y-.....�•�-.� �-,-�F,.�=yam—.-_� <br /> FEE <br /> I LESS <br /> PRORATION / <br /> PLUS — <br /> PENALTY �_.... <br /> OTHER - <br /> . OTHER - .,,.. - r �- • - <br /> Received-by Date Receipt No. Permit No. issuance Date Mailed Delivered <br /> - 'APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AYE.,P.O.Box 2009 .STOCKTON,CA 95201 <br />