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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 3 APPLICATION <br /> (For kion-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicayon Is hereby made to carry on busir4gs int e'unsdictional area of the Sa J quin Loc I He !th District ,-, r <br /> ,,;.Business Name (DBA) l-�� ip{�LT 1! LL OV, Address - -`) - <br /> z Owner LEtz .WW � X-L,_ Address , <br /> J Firm Partners; Addresses and Te e Numb rs 4 <br /> p _ <br /> aBusiness Telephone No. Emergency Telephone No, 4 <br /> Contractor Licence No. <br /> LApplicantsNalre{Pririt)'` a-` L Title ate <br /> Please check Applicable Category (1-7)and Fill in the Required,lnformation <br /> 1. ❑,tPVMPFR VEHICLE PERMIT REGISTRATION (FOR EACK VEHICLE) r <br /> Fo July <br /> 1_ f -`''tJune 30 19� Disposal SiWs, <br /> Description(Make/Yr., Color) �pp <br /> Serial No. CAL. License No. { CAL. License Renewal No. .1 . <br /> -.capacity -Gal—Weights-&-Measures-NoT - <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 /> -3,0-PERCOLATIONTEST <br /> j <br /> R.S. or R.C.E. Name �t '� ' � R.S. or R.C.E. No. <br /> Test Location t Test Date/Ti,ine <br /> 4. ❑ SANITATION PERMITJob Add Add 'SS/Location <br /> Owner -I'�tom, �r � Address - rr J IE <br /> ❑ SEPTIC TANK ❑ CE;SSP,OOC.�• O'LEACHING FIELD SEEPAGE PIT. _� <br /> PACKAC?E_PLANT �.�� <br /> t , r i - ❑ OTHER <br /> 1 t <br /> ❑ PERMANENT ❑ TEMPORARY g D NEW MEPAIR <br /> 5. ❑ CHEMICAL.TOILET}S For July 1, June 30, 19 I <br /> Type Construction i. Disposal Site -_ - ct <br /> No. of Units,Equipment Storage/Cleaning Location(s) i <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name t € Where.Certified <br /> v ' <br /> Plant Location <br /> Plant Capacity i No. Units Served § <br /> 7. ❑ LAUNDRY For Jully 1, -June 30, 19 <br /> SIZES ❑ Less Than 1,0b0 Sq. Ft., © More Than 1,000 Sq. Ft. ` <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. i - <br /> (Home ownrerorlicensed;&gent'ssignature certlfiesthe following;"I.certify that intheoarfarmlincaofIhcwnrMoruthlchthis parrn#tIslasu0., wr nismplg I3l}Y{}@Fllpfl <br /> in such manner as to become subject to workman's compensation!aw,� Df f lilon-J.0 -.. <br /> Con`tractor's hiring or sub-contracting aienature rc;tifinc th.n 'Aito4vinG: '��:';;;!';',I;uj 1r,(Im pGi i31`t°T4flt ';1fic work for {Fjl�li thi1JrpI,n11t IS Mad!040 <br /> ern t y persons subject to workman';compensation laws or Cali;urnra.' r— 3 <br /> thereby certify that I h ve pre ed this appli on and that the work will be done in accordance with San Joaquin County <br /> r ordinan .. d rules d re lation o the a J n Local Health District. <br /> APPLICA'NT'S SIGNA <br /> i <br /> ! t ' S <br /> FOR DEPARTMENT USE ONLY <br /> Fee'IS DLIB: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> i BILLING REMITTANCE $ REMIT d <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE R M)TTED AMOUNT <br /> FEE :f ply ; i <br /> LE9S <br /> + PRORATION t <br /> PENALTY . �+ *fir <br /> OTHER, - V ✓ - It- <br /> f I <br /> OTHER, ` <br /> Re eine ate Lt Receipt No. mit W I[ ti "'ilssuance•Date Mailed Delivered <br /> t <br /> APPLICANT—RETURN ALL COPIES TO:" ENVIRONMENTAL HEALTH PERMIT/SERVICES f 1&0 E.HAZELTOAVE.,P.O.Box 2009 STOCKTON,CA 95201! <br />