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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, <br /> APPLICATION •--' �`k �' <br /> (For Non-Transferable, Revocable,and Suspendable) e_ <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applic tion is hereby made to carry on bu ess in the jurisdictional area of th San oaquin.Local Health District <br /> y Business Name (DBA)W � Address .' G`. <br /> aOwner . ..,. :•i, Address .: <br /> J Firm Partners, Addresses and T I hone Numbers <br /> aBusiness Telephone•No. d - Emergency Telephone.No. <br /> �.� <br /> �Contractor Licence No. . . _ 2 ' <br /> Applicants Name (Print) - Titlei�'� _.pate <br /> Please check Applicable Category(1-7),and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r.1. <br /> For July 1, June 30,19 *��. ,Disposal Sites - C) <br /> 1.Description(Make/Yr., Color) 1 <br /> Serial No. CAL. License No.: CAL. License Renewal No. <br /> Capacity' GaL,.Weights & Measures No. �c <br /> Equipment Parking Address t f <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 .-1 *+° <br /> No. of Vehicles Stored <br /> j <br /> No. of Chemical Toilets Stored <br /> s <br /> 3. 11 PERCOLATION TEST r.^� _ •� - ,:y ' tr"[ fes;`` ��� (,� <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. r <br /> Test Location f x Test Date/Time -k <br /> 4.)K SANITATION PERMIT 1 t f T„ "' `. --� �.. M► �„ <br /> t Job Address/Location 4 : /V <br /> Owner 15213 11 Address flc..9. <br /> 09 <br /> S�EPTIC TANK El CESSPOOL ' LEAC HINGiFIEL'D f °SEEP <br /> 09PAGE PIT ❑ PACKAGE PLANT <br /> ERMANENT ❑ TEMPORARY ' ❑ NEW s T REPAIR ❑ OTHER <br /> S. 11 CHEMICAL TOILETS For July 1,-June 30: 19 <br /> Type Construction• -- .: Disposal Site �•-•-. -.�; -< -f_ {� <br /> No,of Units Equipment Storage/Cleaning Location(s) <br /> j 6. ❑ PACKAGE TREATMENT PLANT F,or July 1, --June 30, 19 <br /> Operator Name .f Where Certified""" <br /> Plant Location ! * - _* -'• a+ .Q» �--. . �. : <br /> „Plant Capacity t No, Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 i. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., More Than 1,000 Sq. Ft. n <br /> ❑ DRY CLEANING, Chemicals Used/Amount/mo. <br /> I� <br /> 1 <br /> a HOmeowner orcansadegent'sslgnatareceriFi?irstAetofkewing;^I certify IfIRt in thg performame of the Yvark for wbi(:h this permit Is issued.I sha it not elTip,loy a'y person <br /> in such manner as to becomesubj%t to wo4mart's compensation laws of Cafifomia.'� <br /> ;. Cont-0tar s hiring.or sub•contracong cignaturo '. _`!-cecerq%s the foijlai rtify that i;1 the,lkforritance of ft work ID_r.W*h tuts'Permit is7Ssued,I shall <br /> t einplay person subject to wotkmarfs compertsa ion laws of Catiforrtia.' <br /> ' I hereby certify that I have repaed this-application and-that the work will bed one in accordance with San Joaquin County— <br /> ordinances,stato laws, an :pare <br /> regulat' ns of the - Joaquin I He�Ith District, <br /> 1 . 1 <br /> APPLICANT'S SIGNATURE,X <br /> . .0. <br /> k, <br /> s , ad k <br /> t [ - FOR DEPARTMENT USE ONLY <br /> ' i Fee Is Due: ❑.ANNUALLY ❑ PER UNIT, 10 PER SITE ❑ EACH ❑ January 1 &Received By January 31,- ❑.July 1 &Received By July 31 <br /> . BILLING REMITTANCE AMOUNT DUE CHECKED <br /> a DATE - DATE REMITTED '� REMIT <br /> BASE EXPLANATION <br /> I AMOUNT <br /> r FEE �J i + t,. 4C 4 <br /> LESS $ <br /> r 3 PRORATION1- <br /> PLUS Y t {{ <br /> PENALTY - . ..•� •..�--,-- <br /> rt.OTHER. t t ' it <br /> "'s.""i• . 14M.Wlw' '9•+ --x.. •9+r - :w*c, -v.e w.++ -.....Tim- ...«... <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issua ce Date, Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ~1601 E:HAZELTON AVE.,P.O.Boa 2609 STOCKTON,CA 95201 <br />