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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />` APPLICATION <br /> 4 (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 /> N Busine s Name (DBA) W AddresV? S� <br /> z Owner 5 �r !� a�/fJ�UAL /q Address 3 0 / "�I 7`/� / 4J/� `t �D c a B l 9 S t/a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No.. Emergency Telephone No. Z a, G��. .. <br /> 4 Contractor Licence No. <br /> LApplicants Name (Print -5 �N r���1�EG� k <br /> Title,�.ow/yF� Date Z� z- <br /> , <br /> i , <br /> Please check Applicable Category(1-7)and Fill inthe Required Information <br /> 1. 13 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 <br /> 2. ❑ PUMPER YARD - r <br /> For July,1, June 30, 19 w <br />{ No:�f`'erhiCles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST "k <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Te t Location Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location 5 <br /> Owner -NrJ �H��D • L ��1 Address el-5 -a /0' 13 7/7L cu ll '( L U/a/, cAwC <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLAN/'L r S z V 6 <br /> 13 PERMANENT 11 TEMPORARY ❑ NEW 7x: REPAIR 0 OTHERt i "° ,_. �• <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19.x. � w' �f „...tom- ;. CA <br /> Type.Construction DisposalSite: <br /> No:of Units - Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 x �(A <br /> V <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served ' <br /> 7. ❑ LAUNDRY For July 1,.-June 30, 19 n <br /> SIZE: i❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> © DR�n4eia6Jj,�41 t�� �,c(.°�,r►�,�Ir�€Ms°the e.ovv;reg_' ccrtjfvth,atinthe;ler(nrmanceoftneworkfnrwhichthis armitisissued,Ishall notemployanyperson <br /> in such manner as io hecome suWpcf to�enryirlan s compunsalion ray.�s n10,�!i;;;;,I< - p <br /> Contractor's hiring or sub-rmtrfttiflg sigrsaiure certifies :?Fe h9lovving., 'I cent;,that in File periermance of the work for which this permit is iss led•I shall <br /> employ persorS.subject to wotkman s compensa.lon lar:s of C�iitorllia." , . <br /> 5 <br /> i <br /> hereby certify that I have prepared this application anal that the work will be done in accordance with San Joaquin County <br /> ordinances, state as and rules and regulation of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE t <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUN <br /> FEE e. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER _ q <br /> OTHER <br /> I 1Ll Y3 S � <br /> Received by I Dat - Ri5ceipi No. Permit No, Issuance Date .Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL'HEALTH PERMIT/SERVICES 1661 E.HAZELTON AVE.,P.O.Box 2004 STOCKTON,CA 95201 . <br /> 1PA�,1(v CW4�YN lb) <br />