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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 /> . T ENVIRONMENTAL HEALTH PERMIT x <br /> LIQUID WASTE <br /> Applica.ion is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name {DBA) " I ��f Address R0 E�& i 41Z_C :MI�2J S>S__Z ] I <br /> aOwner + Address <br /> J Firm Partners, Addresses and Telephone Numbers ^ � <br /> aBusiness3elephone No. t `€� fzd� Emergency Telephone No. W <br /> Contractor Licence No. ! <br /> Applicants Name (Print) Title M A k114 f;7fZZDate 1 —7 —87-- <br /> Please <br /> 8ZPlease check Applicable Category (1-7) and Fill in the Required Information F <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. KSANITATION PERMIT _ <br /> Job Address/Location M C2� <br /> Owner Qeir s t_or, tSQ;L3 � 4-.�� <br /> r. Address r <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 .�. <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 CA <br /> Operator,Name ' Where Certified <br /> Plant Location — <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Hoare Aw(wror licensed agent's sig"vot:rR eartifi"the following:"I of fhewcrk t or which this permit is issued,I shall notemploy any persolt <br /> 1!ti Stich m8n-er 4S tc hftcu c Subject io wGAmP s r7f?m"_a.IIOn!,;wG 01 Ca1if,)mia_ <br /> Contract6+'s hiring or euh-snntrRCYi7tg sir_•nature certiRes 1hE fetlowing; 1 Get'ity that in the performance of the verk for which?his permit is issued,I shall <br /> employ parsons 5:Aeel Ie 140ri;man's compensatinn.!a3r,s fir(.,^tiietni3.` <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I ordinances, state laws, ules and regul ions of the n Joaquia Local Health District. <br /> APPLICANT'S SIGNATURE <br /> 9 <br /> t a <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 0 EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 3. REMIT <br /> BILLING REMITTANCE $ <br /> BASE � EXPLANATION DATE DATE ,REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> / / 00 <br /> FEE 5 — �''7"� <br /> LESS <br /> PRORATION - - <br /> PLUS / <br /> PENALTY (� <br /> OTHER <br /> QTHER <br /> ` t <br /> Re ewes by Date Receipt No. Permit No. ssuance Daae Mailed Delivered <br /> .r <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> A <br />