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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> �/ nkQ� I 1 (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> 1. , V I ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to c%w on business in the jurisdictional area of the dSan Joaquin Local Health District <br /> ,y BUsinesS Name (DBA) Au•MC3/4C4.) a"PIHZZA Address- : 2`9 W ALM LaD I <br /> Q Owner T 4.1-0 G U F Address PO 'Q 0x 1U U 3j:�? _�S'}�e_\e�r•v� IV—z/d <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. s1 G 8r 6 6/A Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) ZZ Title ` :Date. �•"g� <br /> Please check Applicable Category(1-i)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. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored PAYMENT <br /> No. of hemical Toilets Stored VED <br /> 3. PERCOLATION TEST <br /> a.Bvof R.C.E. Name �TP.�t^✓w�l A2.Za 4..49 er R.C.E.No. 1!!J SEP 2 198A <br /> Test Location �;08� arn�\� "2d Test Date/time <br /> 4. ❑ SANITATION PERMIT SU 8�—�� IRONMENTAL HEALTH <br /> Job Address/Location PEIT� UIEz� (n <br /> Owner Address O <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 Q <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) 1� <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> i <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served r <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 3 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Hwn•owmror6e•w.•dpsne'•alBrutur•wrMfi•B+Mtala.WeB:"I certify Lhar 11 thelmrtnrmance ofthe woN for which this permit is issued.ishalf not employ any person <br /> In such manner a-tobaro^:e subject to warkmae-cauln+;nsa!im: C.% o.... <br /> Contractor's hiring sub-cwrhoodng aBrtetum eartiffee the ronaWlry: ,c.r41,'liwi in the performance al the work for which this permit is issued,I shall <br /> employ parsons Lalli to workman$compensation laws ofCalitolnia.' r <br /> I hereby certify that I have prepa# this applicati nd at the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rule d regulation i than Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X (J' <br /> S <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 July 31 W <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE f`� O•00 Q <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER �•s•�.--�� ,7y�� <br /> �Vv •KS✓ <br /> Recei ed.by Date Receipt No. Per it No. Issuance Dele Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009; STOCKTON,CA 95201 <br />