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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) SEPTAGF <br /> —ff�T ENVIRONMENTAL HEALTH PERMIT <br /> '2`Z LIQUID WASTE <br /> Applic tion is hereby made to carry on business the' . d't tional area of the an uin Lo al H , I h istrict <br /> H Business Name (DBA} �1\� . �RL__L •� ress <br /> z Owner — Address <br /> J Firm Partners,-Addresses and Telephone Number <br /> IL <br /> Business Telephone No. -- Emergency Telephone No. yyi <br /> -J Contractor Licence No. _ - <br /> t <br /> Appl-icants Name(Pririt)r' `- Title to - <br /> ° <br /> Please check�Applicable Category._(1-7)and Fill in-the Required Information <br /> PUMPER-VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />" <br /> or JulyJube 30, 1'9' Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. f1" "' CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures <br /> Equipment Parking Address rt� <br /> 2. � PUMPER YARD � � <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored ,. <br /> No. of Chemical Toilets Stored <br /> -1-0--PERCOLATION-TEST <br /> -- - - -?w-- <br /> t : <br /> r R.S.or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location � Test Date/Time <br /> 'A. ❑ SANITATION PER I, <br /> F <br /> Job Address/Location ' <br /> Owner Address <br /> EPTIC TANK ❑ CESSPOOL EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT t <br /> LJ PERMANENT © TEMPORARY WNIEW Ii REPAIR <br /> ❑ OTHER f ' <br /> ,'S: 13•-CHEMICAL TOILETS For July 1,-June 30, 19 <br /> rT�a Construction Disposal Site <br /> 'No."of Units Equipment Storage/Cleaningl-ocation(s) x- ) ; <br /> .* <br /> C-❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> , <br /> OIator Name ! Where Certified <br /> Q� <br /> Plant Location } I <br /> Plant Capacity No Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 '` y k - -r--�.-- f <br /> ,� <br /> —SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More*`h`5n1,000 Sq. Ft. <br /> ❑ <br /> y <br /> DRY CLEANING, Chemicals Used/Amoun_C/IiAo. <br /> Home owner or licensed agent's uignattomeertifiesthefottnuling-."t certify that in the performance of the work for which this permitisissuad,Ishalfnot employ anypersEn .•i <br /> in such manner as to become subject to workman's compemation laws of Ci fifornia." l i r`1., � 'e.1 ;7 c, j <br /> �- Contractor's hiring or sub-contmeting signature rnnifie`the following: 1 rerlilylhut in the pe3itkrniancu of the Trask lar s•N h tics pcsmit is issued,i sha.i <br /> employ persons subject to tiyorkmari s comgeasatian lay::s of <br /> �/ <br /> `- 'I hereby certify that I have prepare this appli tion d that the workSwill be`done iri accordance h San Joaquin County <br /> ' ordinance �teJa s, and r s an a ti <br /> th S n� uin Local Health District. # <br /> APPLICANT'S SIGN - <br /> ,f1,1Ti, J FOR DEPARTMENT--USI=ONLY <br /> _ _ T <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH � January 1 �Rece� d By Jariva'ry 311 ❑ July'1 &Received By July 31 <br /> - REMIT <br /> f8ILL N' REMITTANGE'+[ $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED , <br /> DATE` ', DATE �•- '� - MITTED„ i AMOUNT ? <br /> 'r E ' <br /> f FEE' <br /> LESSfc <br /> PRORATION * S4l <br /> PLUS _ a <br /> PENALTY r <br /> M„a. <br /> OTHER w - .,?. i 43s`. - ; 3 <br /> OTHER <br /> ..e�L'�'T'. • .--�- ` .` M -* r err -f_'�."_'7. , , , <br /> Date <br /> Received by - { - R ceipt Nor- T Permit/N0...r.,., ¢ '� Issuance Date- '-y'�M ildd G,[ <br />. APPLICANT—RETURN ALL COPIES TO` ENVIRONMENTAL HEALTH PERMITISERVICES -�-'- 19019.-HAZELTON AYE.,P.O.Boa 2009 - STOCKTON,CA 95201 i <br />