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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application: <br /> 1 <br /> APPLICATIONiii <br /> ;�. (For Non-Transferable,Revocable, and Suspendable) '' ,` f"'SEPTAGE,.F J "t <br /> ENVIRONMENTAL HEALTH PERMIT'S rr <br /> LIQUID WASTE <br /> Application is hereby made to car on bu,lnnes�s,in the jurisdictional area of the San Joaquin Local Health.-District... <br /> Business Name (DBA) ,�. • �* l�I �2C • Address <br /> z Owner Address _. ... . .. _.. x <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL CL Business Telephone No. 4(Q.�" d� t Emergency Telephone No. i <br /> Contractor Licence No. <br /> a Applicants Name (Print) t'ArY.?L��f :r -�ji]�-�[� Title.ncr ASG�� - Date <br /> Please check Applicable Category(1-7)and Fill in the RequiredInformation ( t0 ft1 .14y o <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 4 Gal., Weights & Measures No. I <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. ❑ PERCOLATION TEST 't <br /> .J <br /> R.S. or R.C.E.Name R.S. or R.C.E. No. <br /> Test cation�__ _ Test Date/Time <br /> 4. X,,SANITATION PERMIT <br /> Job Address/Location <br /> Owner 7PD Address ��� L-E,� �1 It. <br /> ;SEPTIC TANK ❑ CESSPOOL' ❑ 11LEACHING FIELD SEEPAGE PIT 11 PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑.NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,�-Jun_a 30, 19 a l c <br /> Type Construction -' -Disposal Site:--J <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For:J,uly 1, -`June 30,<19.. <br /> "Operator Name r " ' Where Certified�- <br /> Plant Location <br /> _. -� W Kw-w.•-r <br />_ Plant Capacity a 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. t <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.' <br /> t<omeowrrerorlicensed ag+nr'asignaturecorttfi amete+I�+vii, tcer`i'yt'satin?he -r'ov; anceo'thewo&fore.!hIChthispermitisissued,ishailnotemployanypersc. <br /> in such mailer as to become subject to wort—,man's campensatiun lWs of Calitornia % i <br /> Comrscctor's hlring'ar'aub-cant=mJ`sictnature-certifies-the iallvtving: :'i Certify that in the pwlormance of the work torwh'sch this permit is issued,I shalt <br /> employ persons subject to workman's compensation laws Of Califofnia' - <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count <br /> ordinances, state laws, an u sand regulatio of the'San J in.Local Ith D rict. � / <br /> "APPLICANT'S SIGNATURE X <br /> - FOR DEPARTMENT,USE ONLY _. <br /> s <br /> Fee Is Due- El-ANNUALLY ❑ PER UNIT 11 PER SITE ❑ EACH, �❑ January 1 &Received By'January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE-I $ AMOUNT DUE CHECKED <br /> DATE BATE ;REMITTED r AM011NT <br /> p <br /> FEE <br /> LESS <br /> PRORATION r - <br /> PLUS s i <br /> PENALTY e ; .. v.t� •- <br /> OTHEH..; <br /> F ^P <br /> Received by Date Receipt No. Permit No. I sua c pate Mailed r Delivered' r - <br />,+� a APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -7601 E. AZELTON AVE.,P.O.Boz 2009' -STOCKTON,CA 95201 <br />