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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> &803 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 /> ,r;Business Name (DBA) Briu 16ach 4f lazza Address 3323 W Elm? Lod <br /> z Owner Glen Brio '7bach Address Snme <br /> J Firm Partners, Addresses and Telephone Numbers � �,Zn 5an7e <br /> IL <br /> Business Telephone No. 3(6 66!8 Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print)—Glen I QaLlmhors f7kv-dOhn& k1ritle R•C,6•126W Date 2/ <br /> 78.6 <br /> Please check Applicable Category(1-7)and Fill in the Required Information �1 vi/E179 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. 11 PUMPER YARD n <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored 0y <br /> 3. 19 PERCOLATION TEST Al S88"? A-R 5' <br /> R.S. or R.C.E. Name rMea T 13 jj:/inboL.r R.S. or R.C.E. No. 126Fjy5 <br /> Test Location Jpi1a 02nk7a'r°i7-- _ 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 <br /> No. of Units Equipment Storage/Cleaning Location(s) <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 <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Naneewnerorficen edegent,selilinature certifiesfhofoRovMV;"i C.^rti•y•h••:_�., ,e,•�•1a�cc'nrthCwerkfpra <br /> In SUCH 111af1f1Pt ac t0 hSCO. a SubOct!o�vorkSt,i'!�'. 60 �;;diK••+•;aMS�i` <br /> Connector's hiring or sub-contracting sigrwtvre w.a WO, r -,IkwMS,. <br /> employ persons subject to workrnan s coiWensation lav;,o. <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 regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY (. 'J <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Re �`y 9uly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMO ^ KED <br /> DATE DATE REMITTED n h 'J AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receiydyby Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> A (CANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />