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D pp(icttit ' Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. � l <br /> 1 APPLICATION <br /> 4 , ,UIN LOCAL (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> SATS LTH ENVIRONMENTAL HEALTH PERMIT <br /> HEATH DISTRICT LIQUID WASTE <br /> Application is eby made to carry n business in the jurisdictional area of than Joaquin Local Health District <br /> Business Name (DBA)ra,Qf?I S �bluri_, C, _ Address_I��a Jt11C z5/--s 0, jrY_2_O <br /> aOwner Address _... .. - <br /> J Firm Partners, Addresses and Tele/one N ers N <br /> a Business Telephone No. O. ' 6Q 7 Emergency Telephone No.- <br /> � : <br /> 1 Contractor Licence No. f_ 3ly 3 <br /> Applicants Name (Print) t C F01 Title Dale <br /> Please check Applicable Category (1-7)and Fill in the Required Information T <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. 1 <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 ocation Test Date/Time <br /> 4. SANITATION PERMI <br /> Job Addr /Location �� P-6 A✓ C� <br /> Owner G6,4 1.944J Address 1,49ON C77 <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY 19 NEW j ❑ 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 Y <br /> Operator Name S. -Where Certified <br /> Plant Location ( t <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. t <br /> 1 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home owner orlitemied!^t?ertt'ssigraturnr,9rtifi"thefottowing:"tcertib.,that inthe prrformanceoftflework for wNchthispermit is issued,Isha;ir.,. Tpioyan -,I <br /> ir.such rna.lncl as to-�ec0mll subjr:tt to workinal�s Compensation laws Cl Cafilomia.' _ � yG"' " I <br /> Contractor 3 hiring or sub-contracting signature ccrtiffes the fallowing: -'I cerli€y that In theperfoiml nro of the work for which this pgrmif s;,sad,i sl.ail <br /> employ pefsofm subject to workman's compensation taws of Caii#&rlia" <br /> I hereby certify that I have prepared this application and that the work will be done in accordance withSanJoaquin County <br /> ordinances, state laws, and rules and re ulations a San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X_ �� \ <br /> FOR DEPARTMENT USE ONLY- . <br /> 3r' <br /> Fee IS Dile. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January.l &Received By January 31 ❑ July•1 &Received By July 31 <br /> y' BILLING REMITTANCE $ REMIT <br /> SASE EXPLANATION i AMOUNT DUE CHECKED <br /> DATE DATE,, - REMITTED - AMOUNT <br /> FEE <br /> r # 4 <br /> LESS ..{n�i�/ .► r i . <br /> PRORATION CI.L/!'- � v <br /> PLUS ! N /O'- 1S'JSP <br /> PENALTY �� - <br /> 171 <br /> OTHER t <br /> OTHER - * s•. <br /> a - <br /> Received by - Date Receipt No t ""' P,ermit,No:Ja Issuance Date Mailed Delivered <br /> .�- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISEFIVICES 1601 E.}iATELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201- � <br />