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' Applications willte 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 <br /> Appllcatlon Is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District. s _ <br /> F Business Npme(DBA) ` Address <br /> Owner L. N 1 E F— N A q Ja Address '� // f fi 09 F SC'4 <br /> Firm Partners, Addresses end Telephone Numbers, <br /> E. Business Telephone No. et -t - d SJ Emergency Telephone.No. <br /> Contractor Licence No. p, <br /> ��Applicants Name (Prints &7 & #.z -M .Title, ti Date, <br /> Please check Applicable Category.(11 7) Fill In the Required Information ! <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) ppppCCCC' <br /> For.July 1, June 30, 19 -. .Disposal Sites. - - - V <br /> •Description(Make/Yr.,Color) <br /> V <br /> Serial No. CAL. Licanie No. CAL.License Renewal No. <br /> ' Capacity - - Gal.,Weights 6 Measures No. -- - - -- ---- <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> ' No. of Vehicles Stored <br /> Ne.of Chemical Toilets Stored <br /> 3. ❑ PERCOLATIONTEST <br /> ' R.S.or R.C.E. Name _- R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> AC Job <br /> 11 SANITATION PERMIT 1 <br /> Job Address/Location ;2 � / //r �i V-e:- �c, <br /> Owner L 0/17.1"per--%PAN 9 00-k— Address 12-17 <br /> SEPTIC TANK. ❑ CESSPOOL �Ely LEACHING FIELD r[] PAGE PIT�P' ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY Aa NEW ❑ REPAIR ❑ OTHER +" <br /> _6. ❑ CHEMICAL TOILETS For July 1, Jpne 30, 19 <br /> .Type Construction. � Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) ' <br /> y <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30,19 <br /> Operator Name _ � i -t �:rAiInS Certified <br /> 1� <br /> Plant Location s t <br /> Plant Capacity _No.Units Served- <br /> LAUNDRY <br /> erve LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,. ❑ More Than 3,000 Stjr Ft. I. <br /> 75 <br /> 13 DRY CLEANING Chemicals Used/Amount/Mo. !^.! 1 �'' - r <br /> Homeownarorticerned agent's sigraturonordtiestha following:"I Certify thnfin ilia pefArrr(6.d, jlh V.. r� lle,this permit is issued,1 shall not employ any pgrson <br /> ' In such manrror as to become subject to 1vorKmali s cmr crrac;oli lav✓s of i:aiirorn:." y`•' �`. ` ,I <br /> Contractor's hiring or sub-co Me sig c^ +ties d+a 4oitovrinDe "I L-I!ify,that 1.1 ,.. ,m',cc of ilia work for which this permit is Issued,I shall I <br /> employ persons subject to workman's comp tion laws 1 0 IM111ia: <br /> I hereby certify that 1 his appl tin and Shawork done In accords.nce with San f qu�C�pty <br /> tordinances,state the San Health District. 11 <br /> APPLICANT'S SIGNATU <br /> ' - FOR DEPARYM9NT USE ��`` Imo' <br /> I <br /> V { <br /> Fee Is Dae: ❑ ANNUALLY [I PER UNIT ❑ PER SITE rv„r1 EACH 10`anuary Ta Recaiye0 By J�pJ ry^,3.1 El 1 S Receives MI July 31 <br /> . . . . REMIT _ <br /> ' BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE 'REMITTED AMOUNT <br /> o� �SFEE . . b� ' „- <br /> LESS <br /> PRORATION MILK <br /> PLUS <br /> PENALTY- <br /> OTHER <br /> OTHER <br /> ' Received Oats R I N Permit No. IMua Mailed Delivered 9 <br /> APPLICANT-RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E 1012E VE.,P.O.aw 2009 STOCKTON,CA 95201 <br />