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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 hereb.��ade to carry,on businessjn th2 jurisdictional area of the an Joaquin Local Ith District �j <br /> rBusiness Name (DBA) /9� e:5 f7 �l Ipye'rr/ ri'S-56c. Address ?�J�1 Al. h/q� `� <br /> a owner 44y�/E �. doeOeuM Address /405s/ tib14CW/LA � <br /> J Firm Partners, Addresses and Telephone Numbers 4.77— 084 9 <br /> a. Business Telephone No. 7— 99 Emergency Telephone No. 4/3-Zz 7Z" <br /> Contractor Licence No. C <br /> Applicants Name (Print) `ice O ZA1� Titl Yt/e r Date -4- <br /> 91 <br /> Please check Applicable Category(1-7)and Fill in the Required Information Rte•f t �/f~��r <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 <br /> No. of Chemical Toilets Stored <br /> 3. PERCOLATION TEST <br /> O <br /> R.S. or R.C. Name �L _5,4/Y6y1A1E1 Tl R.S. or R.C.E. No. 15 31 <br /> :100 140" <br /> Test Location lD S ���,2G�i�a Test Date/Time — / <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <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 <br /> Type Construction Disposal Site `Q <br /> No. of Units Equipment Storage/Cleaning Location(s) V' <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 (� <br /> Operator Name Where Certified _ <br /> Plant Location <br /> Plant Capacity No. Units Served 11 <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> 7 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Homeownero.tteehs degeoYesi�naeureeertifieetMtotlowtng:"IoWlifythatinMeperformance ofthe work forwhichthis permitisissued,ishallnotemployanypersen <br /> in such manner as to tleceirae suhjectio workmadsComponsoon taws of rfornia.' <br /> Contractor's hid or sub-come. c s� nature eertKies dro fol '1 certify that in the <br /> ^$ ting -p lowing: fy perfotmal+ceof the work for which thin pefmi2 is issued,!shah <br /> empty persons sub*t to workman's compensation laws of California.' <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and reuI tions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE , �6�• Q.l�� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Datb Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />