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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ` r (For Non-Transferable,'Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District, <br /> Business Name(DBA)_p•A..PPf4i2 � Address T N Z <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a.c Business Telephone No.. Emergency Telephone No. <br /> Contractor Licence No. - Z -- <br /> L Applicants Name (Print) 'T Title <br /> � ��_ Date.'7I Z �a 2 <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> t, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r•, <br /> For July 1, June 30, 19 LDisposal Sites _ w <br /> Description(Make/Yr., Color) <br /> Serial No. t CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD j ,. <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. SANITATION PERMIT i <br /> Job Address/Location I4.z �- <br /> OwnerRL M1 Address ::SALA E � <br /> ❑ SEPTIC TANK 1:1 CESSPOOL •K LEACHING FIELD XSEEPAGE PIT ❑ PACKAGE PLANT v <br /> J,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 I <br /> Operator Name WheFe Certified I <br /> Plant Location i <br /> Plant Capacity No. Units Served 4' <br /> 7, ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. Y. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - <br /> Horne owner o►IlcensedagenYi x[gemturecertifieethis fo!lawing:'feerti �xtinthepetformanceufthe mrkfor which1hispermitisissueg,lshalfnotemployanyperson { <br /> in such manner as to become Subject to workman's eprrlpensaticlp laws 9f 1;'atHora;,. <br /> emnlo$Et $ h,r,ng or <br /> "'i'aontreettng 5i"Um c&Mf m the fdRO,�,�;ng; 1;,ertiftr:hat is the pei tormptrce v`the warts f or which this permit is issued,I sha[I <br /> employ persons subject'to workman's compensation laws of Califarrlia" <br /> I hereby certify that I have repared this application and that the work will be done in accordance with San Joaquin County f, <br /> ordinances, state laws, nnd regul ns of thJoaquin.L I Heal District. <br /> APPLICANT'S SIGNATURE X ; <br /> ©� <br /> P , • <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY El,PER U NIT 0 PER SITE . ❑ EACH - ❑ January 1 &Received By January 31 ❑ July 1 B Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT ! <br /> ! - DATE y: DATE ,REMITTED AMOUNT DUE CHECKED <br /> � � _ AMOUNT <br /> FEE 1E Z. a0 <br /> LESS <br /> PRORATION g <br /> PLUS i <br /> PENALTY - <br /> OTHER <br /> OTHER µ L' - .N <br /> Received by Date �� 2 �� ���"^ <br /> Receipt No. Permit No. - I ance D Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.IiAZELTO .,P.O.-a 191 <br /> 2009 STOCKTON,CA 95201 <br />