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#kppucaTionsWillBeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> h ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicationjls hereby made/t arry on business in the jurisdictional area of the S Joaqui Local Health District <br /> F Business Name (D&AV) r IAddress ©r p (p7 L�f(&Z Owner [.• EC�r 5 CSL^U <br /> Owner—&-L/-- <br /> < AddressAw <br /> Firm Partners, Addresses a Telephone Numbers -�---� <br /> aBusiness Telephone No. -7-;7_-7-,5_1 <br /> Emergency Telephone No. <br /> -J Contractor Licence No. <br /> a <br /> L Applicants Name (Print) /�'YJ �V / _ Title <br /> Date <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) <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 3_ <br /> No. of Vehicles Stored + <br /> No. of Chemical Toilets Stored # <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name k R.S. or R.C.E. No. r <br /> Test .11 ion Test Date/Time <br /> - 4. k7ANITATION PERMIT <br /> Job A dress/Location ��E. L b <br /> Owne�.� � •L � ��, L 1 <br /> Address <br /> SEPTIC TANK ❑ CESSPOOL 0-tEACHING FIELD OSEEPAGE PIT ❑ PACKAGE PLANT <br /> .PE} MANENT ❑ TEMPORARY ACNEW ❑ REPAIR j ❑ OTHER 't 4:5. ❑CHEMICAL TOILETS For July 1, -June 30, 19 .--.. <br /> Type Construction +' Disposal Site _ a <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ' <br /> Operator Name <br /> Where Certified i - <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> M1 f <br /> 7. El LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., -vt More,Than=1,,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Flemeowner r,rticensedel�ant'SaiC�natct*sr.�-�;f€srtF�ctot�nv, u r ` <br /> permit ermitisissuad,lshatlnotem to an person <br /> II)5lSCli manner a5 to btiGtinll.bif{)j°Ct is 'CI E;r;B.`, �v;,r :iS�t1};', ",.S 4i riel'1?>� employ y <br /> Contractor's <br /> plypersons <br /> hi inguoj or sub-ca,r-:r,:ir£I s; ,z tui, ecrtifi�,F xne fo!;cwing; "I Certify that in t;?'p-Orforn3�nce of the work.for which this permit is issued,I shall <br /> mp ypersons Su�jecf to'w* compensaLon lavis of California." <br /> l hereby certify that I have p red this application and t t e work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and end re ulations of t `Sa J quin Local Health District. rJ <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 0] PER SITE ❑ EACH ❑ January 1 R Received By Januar <br /> I Y 37 July t &Received By July 31 <br /> BASE EXPLANATION � BILLING REMITTANCE 1AMOUNT <br /> MIT <br /> $ AMOUNT DUE CKED <br /> DATE DATE REMITTED <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> r <br /> OTHER <br /> 1 <br /> OTHER / - - -. <br /> Received by ate Receipt No. Permit No. Issuanc <br /> Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEL VE.,P.O.Sox 2009 STOCKTON,CA 95201 <br />