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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 'i APPLICATION <br /> a-ti (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> II LIQUID WASTE <br /> Appl icati n is hereby mad to ca ry prilbusin synth urisdic ional rea of the San Joa uin-Local He Ith District : <br /> rn Busines Name{DBA) �� • 04ddress � T� C.t aka `�—Qh <br /> cOwner ,° 1. .L Address t� <br /> 'Firm Partners, Addresses ano Tlephone Numbers <br /> aBusiness.Telephone No. �— Emergency Telephone No. n <br /> Contractor Licence No. L( t1 <br /> L Applicants Name {Print) L �. �n/��-'�- Title �-d "r C C Date 4 <br /> Please check Appiicable Category, 1-7 and Fill in the Re.q uired Information t ,q: n • .. ,- +; , <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1; _ = "_ June 30,719 d Disposal Sites <br /> Description(Make/Yr.,Color) <br /> Serial No, CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights& Me sures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30 19 .4 <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. l r <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT- <br /> Job Address/Location <br /> Owner P <br /> Address <br /> t <br /> ❑ SEPTIC TANK ❑ CESSPOOL f9 LEACHING FIELD 81'SEEPAGE PIT `❑ PACKAGE PLANT X <br /> ❑ PERMANENT ❑ TEMPORARY JKiNEW ., <br /> REPAIR ❑ OTHER max! <br /> 5. ❑ CHEMICAL TOILETS For July 1, June 30, 19 r� <br /> 'Type Construction' �I -- �- Disposal Site AV\ <br /> No. of Units Equipment Storage/Cleaning Location{s) T `I✓ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 i r ►•�� <br /> Operator Name' - Where Certified, <br /> Plant Location <br /> Plant Capacity ! No, Units Served T <br /> 7. ❑ LAUNDRY -For=July 1.-June 30; 19-"L_ <br /> SIZE: ❑ Less Tham1,000 Sq. Ft.,` ❑ More Than 1,000 Sq. Ft. f ' <br /> L_ . <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ; <br /> Home owner orlIcensedagent's*11fmuturecai fic Thrfollov;nq:71certifytha!i<,ltheperforrtvnceoftheuvoifkfor01bictithispermitislssired,Is,lalfnot-mployartyperson , <br /> in such manner as To becoric svtjed i0 wort ana i CL}r S fl a1dC r!i 4+,.i i1,:i,' <br /> Contracxor's,hiring or sib-r art ct9r0 ,gs t cer'jF ths' o lctr�,f:y 'I certify-'that in t4a performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's cornp;,,,saticn lav s cf t,allforilia.' <br /> I hereby certify that I'have prepared this application and that the work will be done in accordance with San Joaquin County {` <br /> ordinances, state laws, prid rule and regulations f the San Joaquin Local Health District. , <br /> APPLICANT'S SIGNATURE X <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 /> BILLING REMITTAN $ <br /> BASE;1 EXPLANATION AMOUNT DUE CHECKED ' <br /> - �. - I DATE - - DATE REMITTED �'- - - AMOUNT ; <br /> FEES <br /> i <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY' <br /> OTHER `, <br /> - -3-- _.� <br /> i <br /> OTHER <br /> i' <br /> Rtv.1' <br /> Date 1 ' i Receipt No 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 95201 <br /> ii <br />