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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION A <br /> `= (For-Non-Transferable, Revocable,and Suspendable) /J SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> �.Application is hereb made to carry on business in the jurisdictional area of t San Joaquin Local Health District <br /> ce Business Name (DBA) ,C} QIs�, Address <br /> iOwner— Address <br /> L) Firm Partners, Addresses a Telephone Numbers <br /> a. Business Telephone No. �— 07 Emergency Telephone No. - _ - <br /> Contractor Licence No- 7 _;S --- - /\ <br /> L Applicants Name (Print) 11 i Title Date - - V <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,-1 9, Y, _ Oisposa! Sites (� r <br /> Description(Make/Yr., Color) <br /> Serial No. -' _ 4CAL. Ligrse No. CAL. License Renewal No._ -- �� `li► <br /> Capacity Gal., Weights S Measures No. <br /> Equipment Parking Address t ; <br /> 2. ElPUMPER YARD ! t ` . I ` L'' 1 <br /> for July 1, June ' <br /> 30, 19 � i ��� � <br /> No. of Vehicles Stored e ( �i 4 ' �' % y f tt <br /> No.of Chemical Toilets Stored { _ I J �' <br /> 3. ❑ PERCOLATION TEST ~ �k {' r + w t `4 `�-� J <br /> R.S.or R.C.E. Name r ; _; R:S.#1r R.C.F_ No- <br /> resL cation. 'Test Date/.Tirhe <br /> 4. $ANITATION PER IT i <br /> Job Addr /Location <br /> Owner Addr s A <br /> l f <br /> ❑ SEPTIC TANK " ❑ CESSPOOL ❑ LEACHING FIELD EEPAGE PIT! ❑ PACKAGE PLANT <br /> _ t <br /> PERMANENT t '[:]'_I-TEMPORARY ❑ NEW 'i + "! REPAIR' ❑ OTHER l <br /> 5. `❑ CHEMICAL TOILETS For July 1, June 30, 19 t <br /> Type Construction L, Disposal Site T <br /> No. of Units —�+Equipmewt Storage/Cleaning Location(s)-•••••^L +" - <br /> - _ <br /> �6. ❑ PACKAGE TREATMENT PLAN+ For July�1, -June 30, 14 c <br /> Operator Name ' ^f - Where Certified <br /> (Plant Location • <br /> Plant Capacity No.Units Served' <br /> 47. ❑ LAUNDRY For July 1, -June 30, 19—.- - <br /> iSIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. s <br /> ❑ athsocrfcr <br /> DRY CLEANING, Chemicals Used/Amount/Mo. <br /> fiomeownerorticer.9etf Ont ss?gnatunera►tF;inOttufoitewint Icertif;ify lh�tlmarc at ihorratklor ':Ich.�' tisp2rmitisissued,lsial;r�iemptoyanyperson <br /> 1 1 in Such manger as to become subject to workma^s cem{crsatiorl hta•u c I ' <br /> Contractor's hiring or sub-cion-mLtf-2 signature certifies tna foitooling: -1 ceaity;ilat in;he perfcrman e e€the'xork lcr which this permit:�issued,;shall <br /> employ persons subject to y+orkmali s co:npensaiioo laws of California." f <br /> ( i I hereby certify that 'I have repared this application and that the work will be done in accordance with San Joaquin County <br /> 1 ( ordinances, state laws and FS of the oaqui oca H bistrict. <br /> APPLICANTS SIGNATURE X - <br /> i >r <br /> J 5" <br /> FOR DEPARTMENT USE ONLY <br /> ! Fee is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ JAnuary 1&Received By January 31 ❑ July 1 8 Received By J. 1 <br /> 1 - REMIT <br /> 'BASE EXPLANATION Bll.l ING REMITTANCE S AMOUNT DUE 1 CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> c } <br /> FEE ), <br /> jt 1 ay <br /> LESS ! <br /> e PRORATION <br /> PLUS <br /> PENALTY <br /> 4 OTHER <br /> 1 <br /> -OTHER ,.. ., .. <br /> i <br /> Received by Date Receipt No. Permit No - Issue ce Da Mailed - Delivered <br /> �. APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON A .,P.O.1 1009 STOCKTON,CA 95401 <br />