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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> APPLICATION <br /> (Por Non-Transferable;Revocable,and Suspendable) SEPTAGF <br /> ENVIRONMENTAL HEALTH,PERMIT <br /> LIQUID WASTE <br /> Application is by made to ca n buingot in the jurisdictional area of the oaqul oca_ District,.. <br /> Address <br /> F Business Nam A) <br /> z Owner Address L. <br /> a <br /> L) Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No: �. Emergency Telephone No. <br /> aol <br /> Contractor Licence No. r J- <br /> Date <br /> 3 <br /> L Applicants Name(Print) Title _ �r�' a =. <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> For July 1, - June-30,1.9 - _ Disposal Sites - - - <br /> Description(Make/Yr., Color) •` CAL. License Renewal No. <br /> Serial No. { CAL. License No. <br /> Capacity Gah,.Weights & Measures No. <br /> Equipment Parking Address <br /> 2. El PUMPER YARD Q I. <br /> For July 1, June 30;19 + <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored - 1 <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. <SANITATION PERMIT f, <br /> Job Address/Locatiy - � '- <br /> Owner f Address <br /> 11 SEPTICTANK ❑'CESSPOOLLEACHING FIELD EEPAGE PIT 1:1 'PACKAGE PLANT <br /> 11 PERMANENT 13 TEMPORARY EW f�EPAIf�. 171 'OTHER �� /4_%_ <br /> 5. C3CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site ' <br /> Equipment Storage/Cleaning Location(s) f <br /> No. of Units ` <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location s <br /> Plant Capacity No. Units Served I <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 /> Ftorne ewner ar licensed agent's sigMrtture reriik�eslhe tallowFn�t:".!r,�t;fy that ip'tte poiforimanrs of tftework for which this petmit is issued l shall not employ any person <br /> fn such manr�t#I cs to became 5ub;ect to vn oe�:nal�'s#;nr„nuns?'.€Gi'.I 7+',;pi Lr,ltttl?f11cs. < <br /> m such <br /> Contractor's hFrlr,p of sub cor„rs tin? si-tn :`rye,=a'tisies �``b 'aFFuwiny: ;"f cei iiy that in the performwice 6 thv.vork for vahich this permit is issued,t shah <br /> employ persons subject iu Wafkal an's colnpensaliorl lays of ceiitcrj <br /> I hereby certify'that I have prep d this application and that the work will be done in accordance with San Joaquin,JiQeunt <br /> ordinances, state laws, and ru a d regulation f the S Joaquin Local Health District. <br /> I - <br /> APPLICANT'S SIGNATURE X } <br /> FOR DEPARTMENT USE O 1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &receiv d MIT 31 <br /> r 'BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE .-.DATE REMITTED AMOUNT <br /> FEE <br /> LESS _ .. <br /> PRORATION <br /> PLUS <br /> PENALTY- T - <br /> OTHER <br /> OTHER 4 <br /> Issuance ate_ Mated <br /> Received by <br /> Date Receipt No. Permit No. Delivered <br /> ` APPLLCANT—RETURN-ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES 11601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />