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. . .._ _ ...,.,.. ....uu,n,..0 , wl._ny \ ...u. ,.c LWt .aye, I. V Npytrbull..,1. <br /> APPLICATION <br /> (F80 Non-Transferable, Revocable, and Suspendable� SEPTAGF <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicata n is hereby made to cart�on busin In the j ri dictional area of the n��quin i cal ealSq District <br /> F Business Name (DBA) EE W A'L'I' N 'a�( A� ��n� Address— <br /> Owner <br /> (�� V <br /> c OwnerE.�Ff \T _L� Address <br /> Firm Partners, Addresses and le one Numbers <br /> Business Telephone No. d� Emergency Telephone No, <br /> Contractor Licence No. I Lt It <br /> L Applicants Name (Print),�'lL,E. W Pe Thil,- li, Title � r le <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Ob <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 n <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. 11 PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Dale/Time <br /> 4. ❑ SANITATION PE"IL, <br /> Job Address/Location / LV`A t�.,�Q.�� r7s1 fsi cN 4tr'tni{ <br /> OwnerlilA.Sv J� z �__ Address <br /> ❑ SEPTIC T ❑YCESSPOOL - ,piy LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER 51L)5. 10 CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal SiteCA <br /> _A <br /> No. of Units Equipment Storage/Cleaning Location(s) _ <br /> 6. ❑ PACKAGETREATMFNT PLANT For July 1, -June 30, 19 - - <br /> Operator Name ! Where Certified _ <br /> Plant Location <br /> Plant Capacity ar 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 /> Home owner or Ileensedagent's signature c1 i81.a the folh.wingi 1 certify that in the perfermanctof thework for which this permit Is issued,I shall not employ anyperson <br /> in such manner as 10 became subject to workman's compensation laws of cd immliL <br /> Contractor's hiring or subcontracting sigmau re:certifies Iho foaowring- "I certify that in the performance of the work for which this permit Is Issued,1611a11 <br /> employ persons subj o workman's conipensaiiud laws of California." <br /> I hereby certify all�epespajred th Application d that the work will be done in accordance with San Joaquin Countyortlinances,state snd Ce u do of th an;Joe n Loc I Health District. <br /> APPLICANT'S SIGNATURE X L� � <br /> �. FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNbALLY 11 PER UNIT ❑ PER SITE Q'EQ1CH Q..January 1&Rmelmd By January 31 ❑ July 1 &Received By July 31 <br /> L REMITTANCE $ REMIT <br /> BASE EXPLANATION BILLING <br /> DATE DATE REMITTED AMOUNT DUE CHECKED -' <br /> AMOUNT <br /> FEE „� C <br /> LESS �. <br /> PRORATION <br /> PLUS <br /> PENALTYj.�sX. <br /> OTHER T ' / <br /> OTHER <br /> ��(O6 �SSa <br /> Received by J Dal ceN <br /> Reipt o. Permit No, Issuance Daie Mail¢d Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES '1601 E.HAZELTON AVE.,P.O.Bot a009 STOCKTON,CA 95201 <br />