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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 car on business in the jurisdictional area of the San Joaquin Local Health District ' 1 <br /> y Business Name (DBA) W014- F.WGIweEr-S. i0 C . Address 7- QC TORI gSIO2. <br /> a Owner C. C11100CE VJWG, Address <br /> I <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. t�T—`t-4; Z,. - Emergency Telephone No. <br /> .J Contractor Licence No. <br /> L Applicants Name (Print) C. ItHANce: 0 Title ILES Date <br /> Please check Applicable Category (1=7)and Fill in the Required Information. <br /> !,,. "•1'`,.:-'.r.', ..,,E ,� .. .. .... <br /> 1. 0 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, - - -June.30; 19. _ Disposal Sites <br /> Description(Make/Yr., Color) I <br /> Serial No. CAL. License No. CAL. License Renewal No. n� <br /> Capacity Gal„ Weights & Measures No, Vy <br /> Equipment Parking Address 01 <br /> 2. ❑ PUMPER YARD <br /> For July 1; June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. 'K PERCOLATION TEST �+ p <br /> R.S. or R.C.E. Name C+ C &NCE W0 N R.S. or R.C.E. No. + C► S. <br /> Test Location la"IC01 E- WATEPLOO Q-04 Test Date/Time <br /> 4. I] SANITATION PERMIT P.M+ ��L�-"r® FRANK ft' CIR tSTIOAr LucC RCIT <br /> Job Address/Location V <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT 0 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY D NEW ❑ REPAIR ❑ OTHER <br /> 5. 0 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 /> 0 DRY C� ,iaNG C1�emica Used/AmounVMo. <br /> wn�r ar rCCnsC tt'Sujectwnrkmn'sc5(.t!Nk&-iti r;aws"A.'f'�'.,� ,^,"^c'.�';�r-;,,���E 0f;I1C1yQ1'#tf;1r'a.-€:iCli chispermii lsissucd,l si�2.11 R9tCmgl oy arty poi.._ <br /> in such manner as to becornu subject la vvorkaran s romper:satiorE laws of <br /> Contractor's hiring or sub-corrtracting afgnature certiffs tho ;allowing: "i certify that in the performance of the work for whirb this permit is issued,I shall <br /> - <br /> emplaypersons subject to warkfnan's compensation laws of California." <br /> 'I hereby-certify that I-have prepared this application and that the will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and reg San Joa I o 1 Health District. <br /> APPLICANT'S SIGNATURE X <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT Y❑ PER SITE ❑ EACH ❑ January 1 &Received By'January 31 ❑ July 1 &Received By July 31 <br /> - 'REMIT <br /> BASE E: PLANATION BILLING REMITTANCE $ AMOUNT OUF CHECKED <br /> r , DATE DATE. . REMITTED AMOUNT , <br /> FEE a� /�t 'Ira's <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY -- <br /> OTHER <br /> OTHER _ <br /> eceived by I Dath Receipt No Permit No Issuance Date Mailed Deiivem <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009- STOCKTON,CA 95201 <br />