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When bmitted Properly Completed. Be Sure To Sign The Application. <br /> Applications Will Be Processed <br /> � <br /> � APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> 3oQ� o ENVIRONMENQUAL IDWASTE706TH PERMIT rj17 � Zc�t�Cl <br /> Application is hereby made to carry on lausiness in the jurisdictional area of the San Joaquin LocalHHDistrict)e4o <br /> ., .,. re ✓ t ���fyO _ Address <br /> N Business Name (DBA) 777 S� 01 <br /> i Owner y l 1� Address <br /> C <br /> J Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> 0. Business Telephone No. <br /> a <br /> Contractor Licence No. / 66oL—�6/ST Date <br /> L Applicants Name (Print) PSN Title <br /> —r _T---- <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) CAL.License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 m Q <br /> No. of Vehicles Stored <br /> Noof Chemical Toilets Stored <br /> . <br /> 3. PERCOLATION TEST <br /> ,�Ow �/�./�'zy —� R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> -�?!P <br /> Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> El SEPTIC TANK C3 CESSPOOL 1:1 LEACHING FIELD 1:1 SEEPAGE PIT 1:1 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 /> Where Certified <br /> Operator Name <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 /> Nomeowner or licensed agent's signstu rocertffissom foHowwng:'9 certify that in the performance of the work for whit h this permit is Issued,I shall not employ any person <br /> in such manner as to become sobjert to workman's eompmatior,laws et Califerf,6.' <br /> Contn tor's hiring or sub-contracting signature eartmes tha `l certity that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workrtian's Compensation taws of CaFfortiia." <br /> I hereby certify that I have prepared this ap is I nd hat the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, ules and regula i n t e '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 &Recened By January 31 ❑ _ &Received By July 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNTFEE (V <br /> LESS U <br /> PRORATION <br /> PENALTYPLUS <br /> OTHER (C <br /> OTHER <br /> Recerveq Fly Date Receipt No Permit No Issuance pate <br /> APPLICANT RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES Mailed Delivered <br /> 1601 E.HAZELTON AVE_P.O.Box 2009 STOCKTOW_CA 95201 <br />