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AppLICATIONd sus <br /> vor Non-Trana/erabk•R pendabty/ SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio hereby mad to carry on business in the tun fictional area of the San aquin Local Health District t <br /> Business Na a (DBA) Address 7�7 tea•-y[a� <br /> i Ownera� <br /> Address <br /> 3 Firm Partners, Addresses and Telephone Numbers <br /> �J6R Sin 4 Emergency Telephone No. <br /> � Business Telephone No. � 9 Y P <br /> -1 Contractor Licence No. `- Z Z <br /> � <br /> Applicants Name (Print) �' rat Title -V Date <br /> r, Please check Applicable Category(1-7)and Fill In the Required Information < <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> - <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&MeA5urei No. <br /> Equipment Parking Address <br /> r. -2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 - <br /> :No.of Vehicles Stored - <br /> No. of Chemical Toilets Stored <br /> r 3. ❑ PERCOLATION TEST <br /> R.S.or R}C.E. Name - R.S.or R.C.E.No. - <br /> Test Lptation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Locati nn 2 <br /> Owner Address 5 7 <br /> ❑ SEPTIC TANK ❑ CESSPOOL PrLEACHING FIELD PAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW AIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 - - ---' - `-- T <br /> Type Construction Disposal SiteX �LA�L <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> f <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 3O, 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 a,00q Sq.Ft. <br /> ` ❑ DRY CLEANING.Chemicals Used/Amount/MO. <br /> Hwneowaa wlh:env8da encs • f <br /> 9 dt to erk aria cotxisatinlaw'sttrtiryrythalinffleDsdormanceolMeworkfw�.MMhthis permit is issueA,lsllatl nofemploy anyperson <br /> in such manner as to become ssbjeC to werkTa:ls canlpensatlen laws ci r'afilprniz" <br /> CmUsemr's :Hie!11-0rwb-eontnstinp ru;_�.e,caecifrc6 the iabwing: 1 ads';Mat in the performance ui the work for•rhich this permit is Imed,l shall ) <br /> employ personsfIltbject to workman.';cut np IsaSIon izws of 6aidontia." <br /> I'hereby certily'lhat l have•Mpared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules artd r tions of the San Jorma,.. iinn Local Health District. <br /> r APPLICANTS SIGNATURE _ , ®• <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 E Received By January 31 ❑July 1 8 Received By July 31 <br /> BILLING REMIT A, <br /> BASE EXPLANATION REMITTANCE S AMOUNT DUECHECKED, `A <br /> DATE DATE REMITTED AMOUNT <br /> FEEy5 S—f <br /> LESS <br /> FIR <br /> RORATION V <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ele OTHER <br /> 1676,55 <br /> by Dale Rerxipt No. Permil No. 1 a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 11141 E HAZELTON AVE.,P.O.E.20as STOCKTON,CA 115201 <br />