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=tions F sed Wtien Submitted Properly Compleea. tie sure 1o aiyn roc <br /> APPLICATION <br /> 711,11iNVI <br /> Non-Translerable;'Revocable,and Suspendabif SEPTAGERONMENTAL HEALTH PERMIT k L�,, �� <br /> LIQUID WASTE <br /> Tc�} 40 <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaqui nr Local Health District <br /> Rtd�sta�Qr `A ress � .. <br /> Ad ress ' �7 P� B ? <br /> ��Et•� NC .G a27`. <br /> : Owner PlrlreitL: TS9~ <br /> 375-76 <br /> Firm Partners, Addresses and Telephone Numbers - <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name(Print) 4 ;~ Title. C i Y I L-.S—=r-ACtla 9 Date. <br /> Please check Applicable Category(1-7)and Fill in the Required.lnformation A-i$ MA�-t REW-PLAZA LO•f311 C¢% 95?_40 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION FOR EACH VEHICLE) G2�$� �"4(5 <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 /> t��t pl-q 1-=� .. <br /> 3. us.PERCOLATION TEST � Sc)tL_ tL-+� R.C.E. No. "j Q-- <br /> »R.C.E. Name Wf1 ME3 Et Cu 'XIS�> ���� tbt F R - <br /> Test Location t -; i 2 rt_ Test-Date/Time <br /> d <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK 13 CESSPOOL ❑ LEACHING FIELD CJ 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, 18— 3 <br /> �/ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. v <br /> flomeownerorlieeraedagent's atgmt"cerMiesthefollowinq:1 certify thetinthe performance ofthework forwhichthispermltIsissued,Ishall not 4-t yanyp0 an <br /> In such manner as to become subject In workmany compeesation laws of Calitornia." <br /> Comractar's hiring or sub-cantmeting signstwe aerdfies the foilvieinp: 1 certify that id the perfarmance of the work for which this permit is issued,t shall <br /> employ persons subject to wwkmaris colapensajioa laws of California:' <br /> y 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 SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> . REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> / -� <br /> DATE DATE <br /> DAfTE�/ -REMITTED �jAMOUNT <br /> FEE /D 1s"0 r/ /0C �� <br /> LESS <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> OTHER ' <br /> OTHER <br /> Rec v h y[ Date ( Rece Permit No. Issuance Date Mailed Delivered <br /> APPL NT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAIELTON AYE.,P.O.Box 2009 STOCKTON,CA 95201 <br />