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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 /> o �fyk( ENVIRONMENTAL HEALTH PERMIT <br /> y LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health D'strict <br /> H Business Name (DBA) 151i1/r�G / 4 SAY' Address P d' /y0,4 //L� cos rC� GeA <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. '` �3-`���y Emergency Telephone No <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date 4_U <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 L <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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. lad SANITATION PERMIT <br /> Job Address/Lo atiolnnl -�'OOO ;1, #SSoN Rd <br /> IVC TYA�t <br /> Owner A�� j� /-n T!Y Address I-P moi' Jy,,4 ✓�' yt a, <br /> ❑ SEPTIC TANK ❑ CE POOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT n <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW Iff REPAIR 11 OTHER V <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30,19 F,LJ�y g as <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 7K <br /> Operator Name Where Certified P <br /> Plant Location w; <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 301 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> Home owner orNeensed agent's signature certifles the following:"i rr+rtity fbpt in the performance of the work for which this permit is issued,t shall not employ arty person <br /> in such manner as to become subject to workman's compensation taws of Califolz, ' <br /> Contractor's hiring or sub-contracting signature certifies tRr following: l certify that in the pei formance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's compensation laws 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 r e an Joaquin Local Health District. 01 <br /> APPLICANT'S SIGNATURE X <br /> V <br /> ( <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. uan�17 <br /> ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16b4 E.HAZELTON A E.,P.O.Box 2009 STOCKTON,CA 95201 <br />