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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 /> r ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) 14/2 Address -S<O-:5-/ /tom tE�+".s hr!qJ <br /> aOwner = �e� a/_,;A , Address <br /> Firm Partners, Addresses and Telephone Numbers Ze73 4 -7 7 Z7 25F 5S <br /> a. Business Telephone No. Emergency Telephone No. -54_�,L¢ <br /> Contractor Licence No. 4_—_ S' <br /> L Applicants Name (Print) �Q-�/� —� ��^� Title 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 <br /> No. of Vehicles Stored <br /> No. of hemical Toilets Stored <br /> 3. CPIIERCOLATION TEST ISS �t O -tom <br /> R.S. or R.C.E. Name ;;. / R.S. or R.C.E. No. <br /> Test Location 957-5 '!9 ���r��- ��� Test Date/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 /y <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. 00 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> omen -moor+ ensedm9;t'!"~ ���`. ' ' �'�"� tCert?fYfhat!ntheperformanceoftheworkforwhichthispermitisissued,I hall not employ any person <br /> si j .:rf Ca,:,.mia:' <br /> Contractor's hiring or sub-cc t tollowing: "I certify that in the performance of the work fcr which this permit is issued.I shall <br /> employ perS6,,,,,,LLjeet to w;i;:{aa.'.„..tdddo <br /> I hereby certify that I have prepared this applicati dthat the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, ules and regula 'on f n 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 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS } <br /> PENALTY 1 <br /> OTHER J O <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.Box 2009 STOCKTON,CA 95201 <br />