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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> _Z APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> t <br /> LIQUID WASTE' <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) Ff If/� 0100 1� Address��� <br /> z Owner ). Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No.. 397./ T "_Emergency Telephone No. <br /> Contractor Licence No. r-2J <br /> Applicants Name (Print) Gd sY3J L4aQi7. ;Title Date -I? ) <br /> i <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, -June 30, 19 <br /> Description(Make/Yr., Color) <br /> ? Disposal Sites - - <br /> _ aSerial No, � � CAL.License No. KCAL. License Renewal No. <br /> Capacity 5.r I Gal., Weights& Measures No. I <br /> f [3i a. <br /> Equipment Parking Address <br /> 2. [D PUMPER YARD1 t� <br /> June 30 <br /> For July 1, ', 19 Q A�j � +Q - <br /> No. of Vehicles Stored ll %Y- I t <br /> No. of Chemical Toilets:Stored� <br /> 3. D PERCOL-ATION�TEST ',1 s \�, - ► <br /> R.S. or R.C.E.-Name R.S.or R.C.E. No.*_w 'tee a kN_�_ 4+ t1 <br /> Tres <br /> -Location . - #y Test Date/Time <br /> 4. V'SANIT, TION PERMI # � 71 \ �. <br /> Job Address/Location s G _7 1 <br /> Owner 14• kE7-;Z1 C--V 4�'a� � Aadress .4f7V:R­1OD zb, S c <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ �ACKAGE PLANT J <br /> ❑ PERMANENT 1i TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. D CHEMICALTOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site " <br /> No. of Units IE Equipment Storage/Cleaning Location(s) t <br /> 6. PACKAGE TREATMENT PLANT'For-July 1,=June 30-19 <br /> Operator Name I Were Certified <br /> Plant Location <br /> Pian!CapacityNo. Units Served <br /> } -� <br /> 7. 0 <br /> LAUNDRY For Jul'13' <br /> -June'30, 19 <br /> SIZE. ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> OD <br /> CLEANING, Chemicals Used/Amount/Mo. <br /> FtameawnarorTicen�edsrcrt'sni9r:ewr@r, ?fse�ih�'rollaufryg:"t CertifyiftMintheperf0TManeeofTheworkforwhicttthispermRisissued,Ishaltnatemployanyperson <br /> In S11Ch rriaRnBF as?a becitirRR Sok+jLCl i1 uiJ!IS'i.?:?:S COTF"..,.3a1!'.i T?i'i=:)f :'+1rFil&. g <br /> Contractor's hiring orcUl:-ccatrr;z` l In w�^s�,re certl;i;� J_ 1toiluvrir g: "'I Certify that in the performance cl the work for which this permit is issued,I steal! <br /> employ persons subject to worknta,"s t ar,pt esat a>z3uv s ai aiit�;:ia:' <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations o'the quin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPART <br /> MENTtUSE ONLY <br /> Fee IS Due: ❑ 'ANNUALLY ❑'PER UNIT ❑ PER SITE ❑ EACH __ '❑ January k4ceived By January 31 ❑ July 1 &Received By July 31 <br /> ! <br /> REMIT <br /> BILLING REMITTANCE $ " <br /> BASE —E%PLANAT.ION �.,._ - _T_��._�r-, AMOUNT DUE CHECKED <br /> I "-DATE DATE ",REMITTED - AMOUNT <br /> -FEE <br /> LESS <br /> PRORATION— - - - - <br /> PLUS <br /> � � <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Is uance Vate Mailed Delivered <br /> APPLICANT—RETURN ALLCOPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E,HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br /> .. O <br />