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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> • APPLICATION <br /> (For Non-Transierable, Revocable,and Suspendable) SEPTAGE,@ .R <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) r43yP 4!5• ,Am-0'7 Address12-� EK F S! 3 3G,�Td1J <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> K Business Telephone No. !;Aclos- 97/ Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name(Print) Title �� _ Date g` Z n <br /> Please check Applicable Category (1-7) and Fill in the Required Information j <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 Renewal 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 /> 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. g SANITATION PERMIT <br /> Job Address/Location 414 !;_ A6 OHO AZ^ 64 <br /> _ �7�%�7z?y✓ <br /> Owner Address <br /> 1:111 �t <br /> SEPTIC TANK CESSPOOL J LEACHING FIELD IIS SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 v <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑-PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> +a <br /> Plant Location __ J <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 R <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Romoaumer oHicensed agon sign�tr.±rP a^rtt`.ee�thA f�?'s+vin� "I��r i`v 1S3^t ',hn perfr .^a^�e of Shevrork?cr!rl ich this,r,.,m�?is <br /> in suctl manner as to became - <br /> Contrsrtor'b Hiring or zub-c c!nfraciir,3 t.J.na ,13'.CDY..-is_ -'t• ��.r4J.coif: --i l:tl il:a;,, �pct'tii�i,Idi�Cl'Oi-' .'.. .vIG:. , •!'•. - cl` <br /> employ persons subject to workmaa's compensation laws of Calilornia." <br /> hereby certify that I have prepared this application and that the work will be done in accordance withaLJfal+n County <br /> ordinances, state laws, and rules and regulations the San aquin Local Health District. - 7— f C�- � <br /> APPLICANT'S SIGNATURE X Yy <br /> 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 /> - REMIT <br /> BASE EXPLANATIONBILLING REMITTANCE $ <br /> y , DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> S <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS t <br /> PENALTY <br /> OTHER <br /> -OTHER <br /> Received by Date Receipt No. Permit No. Isa ante Datd Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />