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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION 9 r r 0 -TR") va-,& <br /> (For Non-Transferable, Revocable, and Suspendable) 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 /> Business Name (DBA) pool Jh/113h( 1-1 E P/bZZA Address 32'2h W. EL64 E_645T, L,40 <br /> a Owner -rERAY Q/AZ2A Address 323 W ELM ST. LopL,_�o, 9S�4fL _ <br /> Firm Partners, Addresses and Telephone Numbers �1 <br /> aBusiness Telephone No. Emergency Telephone No. 9 <br /> Contractor Licence No. <br /> a Applicants Name (Print) -TARRY P11��2�! _. Title C•EE_ 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 J <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. G3 PERCOLATION TEST PAYMENT <br /> R.S. or6:D Name T��.��nYr� �P/dZ�Q R.S. or .C.E No. Iq� � ��as��y <br /> Test Location -�_2At 44� rqq FRAMMA&E 1a7Test Date/Time <br /> 4. ❑ SANITATION PERMIT MAR i <br /> Job Address/Location _ SA jOAQUjN CfIIINTY <br /> Owner Address p I❑E)r HEALTH SER!l '; <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLAMIRONMENTAL HEALTH 11 N <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER (v <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 1 <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 /> Norse owner or licensed agent'x eigrn^ura aers'Iasthe fotlewi"-"I certify that in the performarc9 of the work for which this permit is issued,I shall not employ any per <br /> in such mariner as to become sut:;ect to r;s,krttaa's:er1 ennati;a carr.of Ca itori.ie" <br /> Contractor's hiring or sub-r 7 r.^ Cr2i^., nignat� •^_rrBfvA,, tim fotio,,Ang: i cel tiff that in the perforrance of the work for which th's permit is issued,I shall <br /> employ persons subjeLi to wo ic,:......S J,i?peas 1a1a5 of Caiivrnla." <br /> I hereby certify that I have prepthis applie on a that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a telfs and reguIa!t!i9Ks San Joaquin Local Health District. �J <br /> APPLICANT'S SIGNATURE X `� - - <br /> FOR DEPARTMENT 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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> ` Z Q q t AMOUNT <br /> FEE `O�Atr �2.e3 5` % ` �147-- J O <br /> LESS <br /> PRORATION <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.Bot 2009 STOCKTON,CA 95201 <br />