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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 /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San.Joaquin Local Health.District,„ + <br /> ,F Business Name(DBA) Address <br /> aOwner 1 1 �. �1�n�n Address s . y 21 rn45 co 5c�-K. +� <br /> J,Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. Emergency Telephone-No. 1 <br /> Contractor Licence No. _ In @ <br /> LAPPlicants Name (Print) Title _v rDate <br /> Please check Applicable Category(1-7).and Flll in.the Req uired,Information <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 I <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No, of Vehicles Stored <br /> No. of Chemical Toilets Stored I <br /> 3. 0 PERCOLATION TEST gJ <br /> R.S. or R.C.E. Name R.S. or R.C.E- No. <br /> Test Location Test Date/Time c <br /> 4. ❑ SANITATION-PERMIT <br /> Job Address/Location (o' S jib, d <br /> Owner AddressC[ <br /> SL SEPTIC TANK -13 CE € LEACHING FIELD ' ITSEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER g <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30�, 19 f <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 t` <br /> Operator Name Where Certified <br /> Plant Location t <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 /> grCl[30WRRSOr�iC9n°eft:pie!i�'ctf�rt:?tL;7`'G�'•flfs�;;tt'.�r :lz�'.ln�,:"1Celtifvt4-stin'1I'.0oerformanceOf.heYJGCkfGC1Y�}Ici�`thispermitisissued,Ishallnotemploy-any personr -. <br /> In S[t£t1 mannQ#';_�f0 BCG;^Cl�frjr`r,'•,lG�;rerltl<<a^. £;;s;;;;,;n StE'Jir is+: 'Gl'Caltl GCM w.+ <br /> 3c CIS., - Y <br /> Contractor's hiring mi sub-contractirg ;igninure certai`ss the following: `i ce;1ify that in the performance of the war'�•for which this permit is issued,t shall <br /> employ persons subject tG workman's cempeitsatror,laves of Caiifornia." <br /> I hereby certify-that I have prepared this application and that the work will be done in accordartee with San Joaquin County <br /> ordinances, state laws, and rules and regul ' of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE XIr■`� `l <br /> FOR DEPARTMENT USE ONLY 4, <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ &uy 1 &4Received By July 31 „ <br /> - - • <br /> REMIT, '.. <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUF - CFiECKtb <br /> DATE DATE REMITTED ''; .,AMOUNT` � <br /> t 1z:5 <br /> FEE CW <br /> LESS <br /> c PRORATION -- <br /> PLUS <br /> PENALTY <br /> IV <br /> OTHER <br /> OTHER - - - - - <br /> Received by to I ,•Receipt No. - Permit No. - Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1541E.HAZELTON AVE.,P.O.Box 2008 STOCKTON,CA95201 . <br /> bs <br />