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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application 's bereby macip to carry on busiapss in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name (DBA) � 4147_zA Addresses w ln'1 — Gy <br /> aOwner- V a- Address <br /> Firm Partners, Addresses and Telephone Numbers .T <br /> /P//4,,7 Z.A <br /> aBusiness Telephone No. _?GEmergency Telephone No. <br /> Contractor Licence No. _ <br /> Applicants Name (Print) Title /Yt/-4 a Date <br /> Please check Applicable Category ( -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 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. PERCOLATION TESTI <br /> Ft 9" R.C.E. Name 222 -- z'Z--Q- -Fl.G.o`R.C.E. No. <br /> Test Location Ev <br /> Jdi!f~e� —" ✓t Test nate/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ 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, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DR H�h�f1D y6r t 1 rW$gf,�(,S�Q�p bt(�f�{�gthe following. certify that in the performance the work far which this permit is issued.I shall not employ any person <br /> in such manner as to become subiec'to workman s cc7peslsa`ioil lav/,i !f G$ifor{iia' <br /> Contractor's hiring or sorb.c.n.r&ctf.,g 9i;113ture cart;fies the following: ••I certify that in the performance of the work for which this permit is issued,I shall <br /> I omploy persons subject to workman's compensation laxs of California." <br /> I hereby certify that I have prepare i s application ar(d th2thek will be done in accordance with San Joaquin Cotyordinances, state I s d regulations o e 1 Jcal 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 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 0D <br /> LESS <br /> PRORATION 09 <br /> PLUS /v <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />