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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) SEPTAGF R2 Q{�2c�sc <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 /> yBusiness Name (DBA) Address � �'�' -0ctrn°N RE�tt�EntcE <br /> z Owner ERYItai KC>f;T Address 2t<A-22 w�_ KMN1'1EFtC'IK- i51 ria=2Qin t- Lr <br /> J Firm Partners, Addresses and Telephone Numbers _ ( At--�I Cpl. 95�0�2 LmiaCA 9SZ4-O <br /> aBusiness Telephone No. Emergency Telephone No. (2oq� 3�E3"28� <br /> Contractor Licence No. <br /> a Applicants Name (Print) WALTZ E CURTi�, Title C11rtL'P -LG IREr_-SL Date 9 -(( <br /> .9� <br /> Please check Applicable Category (1-7) and Fill in the Required Information c'E*k I1S84- <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION FOR EACH VEHICLE 4 i8 ,,cA ) 2- o <br /> ( ) NODI, --� 9529-� <br /> For July 1, June 30, 19 Disposal Sites 4159 <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 n 2 PAf�cEl-5 <br /> For July 1, - June 30, 19 <br /> No. of Vehicles Stored <br /> No of Chemical Toilets Stored <br /> 3. 0PERCOLATION TEST4-tg3nal 52 <br /> R 9-trr R.C.E. NameYyAt C2Cq)�68- 159 fir R.C.E. No. I �r <br /> Test Location 2Lh4« !t br-V-1 c K(Ac C 125S OFF OF Test Date/Time P =— A V-- WEI�.NMbAl <br /> 4. ❑ SANITATION PERMIT A t,� CN IP see ROAD <br /> Job Address/Location <br /> r-A= std O'1` r(, <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19Y,`qt �( <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) n .4 X <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 � <br /> Operator Name — — _ _—_ Where Certified <br /> Plant Location I <br /> Plant Capacity No. Units Served 1�® �/�L <br /> 7. El 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 /> Homo owner orficensedagent's signature certifies the tolbwing:1 certify that inthepertormanreoftheworkforwhichthispermitisissued, shallnot7lo anype <br /> in such manner as to become subject to woNman'e campensatinrrlaws of Ca ifomia" `.0 <br /> Contractor's hiring or sub-contracting signature certifies the following: `t certify that in the performanre of the work for wt Ic`1 this parmit,s issued, <br /> employ persons subject to workman's compensation 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 / <br /> ordinances, state laws, and r les and regula�tionns�of the <br /> -San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X o ���� ems` c�2Z,7 -- -- / <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION -AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> j ^ p r �j) q / !� AMOUNT <br /> FEE { =2 2,W lv� �� b� (� !�l�I fo� IYL41,0 0 <br /> 1 Z <br /> LESS <br /> PRORATION RATION S <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />