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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) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE -- �r � ► <br /> Application is hereby <br /> ymmade <br /> �to carry on business in the jurisdictional area of the San Joaquin Local Health Distric <br /> H Business Name (DBA) //V���u SNL _ Address 4� (Wjy CA '7572-DS <br /> a Owner /N"644 �100 TWO'_OWWA ._--_ Address 672J e, Pt/Qie7iV RD. IRAW2fC4 CA 9.5334 <br /> u Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. 9li�r—fiaAr Emergency Telephone No. <br /> Contractor Licence No. <br /> a9, <br /> Applicants Name (Print) ~10610 Title �C � Date 7 <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, 19 _ <br /> No of Vehicles Stored <br /> No of Chemical Toilets Stored <br /> 3. A-PERCOLATION TEST <br /> R.S. or R.C.E. Name A&"4 7.7 6Ww_z1W R.S. or R.C.E. No. 0 3!3 <br /> Test Location (0:72-1E rC1el9JA/ l�� Test Date/Time "bV _II _ � � '10 — 12,(30 <br /> 4. ❑ SANITATION PERMIT <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 /> Home owner or licenand agent's rrignatlfrA cert''i�s the folI0%vjr g_"1 c-rtiN th't in•tip:art^rm„anCe o <br /> in such manner as to become subjec P:o wo,�kmrr s c;rn =ti f the work ic''Which Ltis permit is issued I shall not employ arty persnn <br /> sof"'I•'c .. • .. <br /> Connectors Erring or sab-corttraccompessatlor�laws.Ing siynatl a nrn,cer V.- <br /> empjoy persons subject to arorkinan's ,L��uy. i ti:y ilio:it,1:16 pertorl�a ice ui the work tot which this permit is issued,I shall <br /> ut Caiiiu'i NisL' Cu <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 rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNAT - <br /> !! <br /> FOR DE ART ENT 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> q �7 AMOUNT <br /> FEE �(ypi��11Z ('�� l !'�/ - <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> //- 7- 9/ r �jl7" <br /> ecerved by Date 'Receipt NoNo. 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 />