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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (for Non-Transferable, Revol able,.and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE . <br /> Application-la hereby ma�ddy to carryQ,_n business'n_thee,-IJurisdictional area of the.S Joaquin Local Health District - <br /> y Business Name (DBA}__ r �. /`ig72R�.S CeC `J��.tt Address µ c7r <br /> aOwner—, .Address. <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No.. Emergency Telephone No. <br /> Contractor Licence No. _ <br /> W. <br /> L Applicants Name (Print) C-' �. _ P Title Date <br /> Please check Applicable Category(1-7)and JFill In the Required Informa in h <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) C>' <br /> For July 1', June'30, 19.x1' --Disposal Sites i <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 i <br /> 2. ❑ PUMPER YARD H <br /> For July 1, June 30, 19- <br /> No. <br /> 0, 19 No.of Vehicles Stored' ` <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION'TEST t t <br /> R.S. or R.C.E. Name } R.S. or R.C.E. No. <br /> Test Location t ) " �a Test Date/Time <br /> 4. ❑ SANITATION PERMIT -#cation <br /> / ^ <br /> Job Address/L /� ,I�r si��-�.�•� �7rcaf� <br /> Owner_.-f 4�t L12 /7410il fll elt, Address <br /> 4 ',;L 1:1ACKAGE PLANT <br /> © SEPTIC TANK © CESSPOOL - •m 'LEAHING FIELD SEEPAGE PIT <br /> 11 PERMANENT CI TEMPORARY. �`VEW{ ❑ REPAIR ❑ OfHER �; T` ,, a <br /> S- ❑ CHEMICAL TOILETS For July 1, -June 30, 19 t <br /> Type Construction Disposal Site r' + <br /> No. of Units' Equipment Storage/Cleaning Location(s) t <br /> 6. ❑ PA'CKAGE TREATMENT'PCANTr For July 1, -June 30, 19 >_ <br /> Operator•lVame Where Certified. ' f <br /> Plant LocationAl <br /> � ' }. € �:`'� �. . ������`• , <br /> Plant Cap city i <br /> .b' No. Units Served <br /> 7. 0-LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.. . ❑_More Than 1,000 Sq. R. t i <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.� <br /> Homeownerorlicensettegen Ys naturerrr2ifie>EthPfallowir1g:"IcertIfythe'il�ei3er`flraanc^.n`t'rc�vc;ktcr !ict;;;i permitisisst�ed.lshallnotemployanypersnn <br /> in such manse;as io becorii0 SuNect to'workman s roiilpr're9afiorl IaYfS Df C2!f€�r.;, )3 �y r <br /> . <br /> Contractor's ?titin$'or Sub-cal7trACtiis'P LSignature Cerafiev Use faltovving: -'E e;,;¢ (>I t ii!file porfor;liarrct 4!i IC�'derk fCr WlliCli !115'pCrnrlt is issued shall .� 1 <br /> employ persons subject to workian's torr perrsa€io'laws of Uifornia." } <br /> ^,�l hereby certify that) have prepared this application and that the work will be done in'accordance with San Joaquin County # ' <br /> ordinances state laws, and ruI s <br /> prep. <br /> tion of the �aquin,Loc a th strict. <br /> - • ,,, f . <br /> ,APPLICANT'S SIGNATURE X } _ v' <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received 6y July'31, <br /> REMIT <br /> BASE EXPLANATION BILLING - REMITTANCE $ AMOUNT DUE .CHECKED l - <br /> DATE DATE REMITTED <br /> •:"AMOUNT 7` <br /> FEE .` ,- A4S <br /> rt�rt 1 <br /> LESS 1' i <br /> PRORATION z N g <br /> PLUS J/ C <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r 1 VoS ' o LAY <br /> Received by ; Date Receipt No. Permit No. I Issfianc?,T)WN Mailed Delivered i <br /> APPLICANT-RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMWSERVICES_ 1601 E.HAZEL E.,P.Q.Box 2009 STOCKTON,CA 95201'-x-- <br /> , `-"/ <br />