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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 carry on business in the jurisdictional area of the San Joaquin Local Health District/ <br />F Business Name (DBA) �J�Aylj/TTE��r Cepr�oYL Address �7rsl vv/GN r16/ L7'y <br />aOwner YZAlk,9 Siss i'iq Address <br />Firm Partners, Addresses and Telephone Numbers <br />vu r <br />aBusiness Telephone No.Emergency Telephone No. to rtg, 7 vs <br />Contractor Licence No. <br />Applicants Name (Print) Duct hAR Svn, •q Title Date <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, 19 Disposal Sites <br />Description (Make/Yr., Color) <br />Serial No. CAL. License No. <br />Capacity <br />Equipment Parking Address <br />2. ❑ PUMPER YARD <br />For July 1, June 30, 19 <br />No. of Vehicles Stored <br />Gal., Weights & Measures No. <br />CAL. License Renewal <br />No. of Chemical Toilets Stored <br />3. JXPERCOLATION TEST <br />R.S. or R.C.E. Name �� i -i r'A/z� E/ /Ei�K N�y� /dE.- R. S. or R.C.E. No. .z•iz5$_ <br />Test Location "'r f}.s�6 126 i Test Date/Time <br />4. ❑ SANITATION PERMIT 3 /e*fS <br />Job Address/Location <br />Owner <br />❑ SEPTIC TANK <br />❑ CESSPOOL <br />Address <br />❑ LEACHING FIELD ❑ <br />SEEPAGE PIT <br />❑ PERMANENT \\❑ TEMPORARY 11 NEW E3 REPAIR <br />S. 11 CHEMICAL TQILETS For July 1, - June 30, 19 <br />Type Construction Disposal Site <br />No. of Units Equipment Storage/Cleaning Location(s) <br />6. ❑ PACKAGE TRE MENT PLANT For July 1, - June 30, 19 <br />Operator Name _ <br />Plant Location <br />Plant Capacity <br />7. ❑ LAUNDRY For July 1, - June 30, 19 <br />No. Units Served <br />❑ PACKAGE PLANT <br />❑ OTHER <br />Where Certified <br />SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br />❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br />NorrMowrror orlieeawdegentb signature certifieethe Wltowtng: "I certi}y that Intheperformance of theworkfor which this permit is issued, I shaltnot employ any person <br />in such manner as to become subjeetto workman s compensation laws of Ca omia:' <br />Conrwotor's hiring or sub-con"ating signature certifies the following: 'J certify that in the performance of the work for which this permit is issued. I shaft <br />employ persons subject to workman s compensation laws of Calilomia.' <br />I hereby certify that I have prepared this application and <br />ordinances, state laws, and rules and Aulations of thg So <br />APPLICANT'S SIGNATURE <br />the work will be done in accordance with San Joaquin County <br />neuro Local Health District. , <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I a Received By January 31 ❑ July 1 & Received By July 31 <br />REMIT <br />BASE <br />BILLING <br />EXPLANATION <br />REMITTANCE <br />$ <br />AMOUNT DUE <br />CHECKED - <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE <br />(� <br />��a r"� <br />�.�•r <br />r•/ (�Cr <br />/rte �}�r <br />l�60 <br />LESSf <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Lzl� <br />Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br />eva u•eur—em mu ei , rnv¢a rn• eumvnuucurei neer ru vevu,rreeemnee ,m, a uerei rnu evc en v.._ nmv crrnn.rnv �. ecru, <br />