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..p ..... .... . ............... ..,...,. ....�......��, ...p.. .� ,.... .r,......... �� ��.� .� �.a. ...� .r,srrrLll[IQfI. <br /> APPLICATION <br /> 0_0 (,—)r Non-Transferable,Revocable,and Suspendatr)` 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 w } <br /> _..._ 3 -tai-Y <br /> Business Name(DBA}� >�'c- r TD d t.r� Address ..„ a <br /> z Owner -- dresses and Telephone 7" <br /> Address �- I <br /> 4 rZTL `77 �.r,35 <br /> J Firm Partners, Ad Numbers <br /> IL <br /> Business Telephone No. Emergency Telephone No.. <br /> -+Contractor Licence No. dM <br /> _ <br /> L Applicants Name (Print)1— #1 �_ f� --Title Date, <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; 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> .:serial Na CAL. License No. CAL. License Renewal No. <br /> i <br /> Capacity ___ Gal.,Weights& Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> _.For JUIy 1, June 30, 19 <br /> No. of Ve es Stored <br /> No. of emlcal Toilets Stored — <br /> 3. PERCOLATION TESZ ! 1 <br /> R.5.or R.C.E.`Name f31J t'f�IN� �a k R.S. or A.C.E.No. <br /> Test Location z 0` __5 A62' �� --- � Test Date/Time <br /> t 4. ❑ SANITATION PERMIT _ <br /> Jab Address/Location <br /> Owner mi Address <br /> 0:SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 13 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 <br /> Operator Name Where Certified <br /> Plant Location <br /> „ Plant Capacity No. Units Served I <br /> 7."❑ LAUNDRY For July 1, -June 30, 19 w 1 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., �'❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. f <br /> I <br /> Homeowwe+or Ficaesedet}enis91 nasuresettlfbslre�otfovlrFng:"ICerif`�y!thatiniheperlormartceof2h?tuorktrarwhichOispermit isissued,I3h,Inot empl <br /> in such manner as to become subject to workrs�?n's comp6i15afion lavas tlt C3rrfrl::t;,< ° oyanyperson ' <br /> _, t:ontrtrctvr s.hiring or anfb.eositrastirtg c�gr areae.cnrtlNes file Sotlgw�r y. "i aeriify.itlal hl the pert mance of the w olk for Whiotl this permit is issued,I shall <br /> employ jz'ersorls subject to woslcman's curllpensatisn laws of California."' . <br /> I hereby Certify that I have prepared this application and that the work will be done in accordance with San Joaquin County J <br /> ' ordinances, state laws, an s a regu ons of a San Joaqui Local Health District. ; <br /> I <br /> APPLICANT'S SIGNATURE X <br /> -. ,� ClE� � '�: �L �a.� � —�✓3�1.. r �" Y"��W_�C,] - "C72.�.�� <br /> v FOR DEPARTMENT USE ONLY - k <br /> Fee Is Due: ❑'ANNUALLY ❑_PER UNIT ❑ PER SITE ❑ EACH .❑ January 1 &Received By January 31 ❑ July I &Received By Jury 31 <br /> REMIT <br /> BILLING REMITTANCE t $ <br /> EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED- AMOUNT <br /> +7 FEE. <br /> .,,,t <br /> LESS <br /> s-PRORATION' <br /> PLUS <br /> PENALTY <br /> r <br /> OTHER <br /> *' OTHER <br /> F/7 _ - 3 <br /> & C <br /> =Received by Dale Receipt No. Permit No. ISSuance Date Mailed Delivereed <br /> APPLICANT-- TURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 11601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 --- <br />