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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carLy on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DBA) Chti P4 16x ZZCi Address '37-5_-W ekM LnrL._C q — <br /> a Owner— 1ise 1��7-_FLCLZLLL Address 2? i 1"C7 Q( 1 - <br /> J Firm Partners, Addresses and Telephone Numbers4r1lax, Bn llr�Gadd-6_64mi ---- - <br /> a Business Telephone No. Emergency Telephone No. <br /> a <br /> Contractor Licence No. <br /> -- Date <br /> Applicants Name (Print) .rJ�c - `�J Title <br /> gory 1-7) and Fill in th -t <br /> Please check Applicable Category 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 TEST �7 1 2 <br /> R.S. or R.C.E. Namep T rr 1"I R.S. or R.C.E. No. F�(p .7 <br /> Test LocationL1f1i'LC+tf�Ll L3 PYriS Date/Time _ <br /> 4. C1 SANITATION PERMIT Lc4 i Ca �5Z <br /> Job Address/Location Mr — 41 -: FCS- rGLI <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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Nemeew9wwNewwillt' noun*GWIW4000Wtybainy; Irert;tyythw Mips+h,rmaoceOfftwork M►which this permit isissued,Ishall not empttyany person <br /> in such mortner as to become sv0(!ct to workman's compensation IawS of Cafifornie. <br /> C XdFaCW'a Will ar .i►saertwe" oigaa>turs wrtiltss the foiiowtrv- t cei lcy that"i the perfor manct,al tho work for which t11i6 permit is issued.I shall <br /> ampioy tferso""biect to norkawn'S compensation taws of California. <br /> 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 pfd V <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> I REMIT <br /> BASE E)FLARYM 1ii,,1-FILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> fTRATE DATE REMITTED AMOUNT <br /> FEE 5b.LV 50'00 <br /> LESS AUG 989 <br /> PRORATION <br /> PLUS <br /> PENALTY ENVIRONMENT U HFAI <br /> OTHER PERMITISERV110ES <br /> OTHER <br /> W 05 <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.Box 2009 STOCKTON,CA 95201 <br />