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f' APPLICATION <br /> i .. For Non-Transferable, Revocable. and Suspenda`Uiie) 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 /> y Business Name (DBA) QU-A rA 12411--1 Address 310 suer, z.jmrr 5rE A µ(aNT��� <br /> i Owner -� � 4- T s'T Address Q � t32--7 mA-�)m,-++ <br /> j Firm Partners. Addresses and Telephone Numbers _ In1G41-ate Z_$_� fir-• WfM--rt-*- <br /> aBusiness Telephone No. _ Emergency Telephone No..--__ <br /> -J Contractor Licence No. <br /> Applicants Name (Print) _ F-4-j4,M-J'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. 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 <br /> For July 1. June 30. 19No. of Vehicles Stored <br /> Noof�Chemical Toilets Stored <br /> 3. L7 PERCOLATION TEST , - ' 1 A <br /> R.S. or R.C.E. Name 1��'' �NN R.S or R.C.E. No. Z�I ZS s <br /> Test Location �2 ^OQ �ot1� Test Date/Time <br /> 4. 1:1 SANITATION PERMIT �� o <br /> Job Address/Location -— <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, 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 - -- <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 /> H°r"e°w^e'o'Iimruaa..'.y..nr's wo natu»certifies th f0lbwing:1 certify that in tate performance of work for which ttus permit is issued l shah not employ any,s <br /> M Such 1Tlannef as 10 become subject IG 710rktlar•5 CSJl1(iB(nSalllrl I.lx'S of t+a+lforri� <br /> Contractor's 1>mrng 0r sub-eontrec6ng signature catrobes the fvl <br /> ernpiey persons subject to wurklnlan s ebmplinsalim,laws of Call:01aldiuwiny: 'I celtily ilial u1 ttte(erformarlce 01 the work for which.ni;pzrmlt Is rssusd,I shat: <br /> ' <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, r es an regu ons of the San Jo uin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> /'�.�C`e,s',.a�y ..�'• :s'./�i°� ez!d �-'��'`^�'.+G' %s•� f- 4. ✓ .G_ / t !lowj� !:'� !�i� <br /> FOR DEPARTMENT USE ONLY AO <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 C] July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED —�— AMOUNT <br /> FEE -— - / —. 15q. - <br /> LESS <br /> PRORATION • _____ -- <br /> PLUS - -- — <br /> PENALTY <br /> OTHER <br /> OTHER <br /> eceved by !D.. Receipt No Permit Nn Issuance Date Mailed Delivered <br /> PLICANT—RETURN APIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Eos 2009 STOCKTON,CA 95201 <br />