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IApplications W"YBe Processed When Submiitetl Properly Completed. Be Sure To Sign The Application. <br />l APPLICATION <br />1 (For Non-Transferabie, Revocable,'and Suspendable)' SEPTAGE <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />I Application i A�aa e to r onpu i ss in the jurisdictional area of the S/arf�JJoaquin Local Heajt �£tric <br />a M <br />` <br />�J Address ' <br />HBusiness Name (D A) QUA' <br />z ,�. J� Address - .•...,.-. .. . <br />a Owner .... - <br />2 Firm Partners, Addresses and Telephone Numbers <br />r-��-� ' Emergency Telephone No-- <br />Business Telephone No.. T <br />Contractor Licence No. - Oate <br />K� -Title _ <br />l Applicants Name (Print) t - <br />Please check Applicable Category•(1-7) and F10 in the Required Information <br />1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />ti <br />For July 1. June 30, 19 -Disposal Sites <br />Description (Make/Yr.. Color) ` CAL. License Renewal No.. <br />— <br />- CAL. License No. <br />Serial No. <br />Capacity —. - Gal., Weights & Measures No. <br />r <br />Equipment Parking Address — - <br />_ <br />2. ❑ PUMPER YARD ` . <br />, <br />For July 1, June 30, 19 — — <br />No. of Vehicles Stored, - - <br />No. of Chemical Toilets Stored - <br />3. ❑ PERCOLATION TEST�- <br />- t--- R.S. or R.C.E. No. <br />I R.S- or R.C.E. Name °r <br />Test Date/Time <br />Test Location <br />4. ❑ SANITATION PERMIT *_ <br />I _ <br />Job Address/Loc <br />A Address <br />' Owner ' <br />❑ ALEA' 6WNG FIELD SEEPAGE PIT ElPACKAGE,�PLANT <br />i ❑ SEPTIC TANK CESSPOOL <br />11 PERMANENT ❑TEMPORARY ❑' NEW �REPA R 13 OTHER <br />19 <br />r 5. ❑ CHEMICALTOILETS For July 1. - June 30, <br />{ <br />Type Construction Disposal Site _ <br />Equipment Storage/Cleaning Location(s) <br />No. of Units <br />6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 Where Certified <br />Operator Name <br />Plant,Location— <br />f .., , - ^ No. Units Served <br />Plant Capatcity_ � - <br />7. ❑ -LAUNDRY For July�l, - June .30, 19 <br />SIZE: ' ❑ Less Than _GWSq: Ft , 11 More Than 1,000 Sq. Ft. <br />~. <br />❑ DRY CLEANING, Chemicals Used/Amount/MO.� - - <br />p <br />y �rsc <br />o any <br />r I <br />-Home Owneror'licensedagent'ssignaturerertifier-thafOliolvin9:"lcertal'thaiinthe{te;torman.eoftheworkforuhichthispertnit'tslssued,lshallnotem <br />I certify tk , t in the pertormsnce ui the tvCrk f or which this permit is issued, <br />in InarJner as to become subject to toots Ian's compensa'.iolt ta'.vs o! (,alitorii:: <br />in <br />subject to vo <br />minatractor <br />l shat <br />such <br />such ;nari'3 a v ^orE:ict `= toHoi-znS` <br />5 hiring or fine <br />subject to c:c, peusat+.on <br />employ persons .tickman's <br />i 1 _ I hereby certify that I have pre red thi application and that the.work will be done in accordance with San Joaquin County <br />the San Joaquin Local Health District. <br />. <br />ordinances;'state laws, and r nd r ulatio of <br />APPLICANT'S SIGNATURE X -- <br />Fee is Due:'0 'ANNUALLY{ <br />7 <br />BASE <br />FEE <br />LESS C-\7 1 <br />-PENALTY <br />OTHER <br />OTHER. <br />❑ PER UNIT <br />FOR DEPARTMENT USE ONLY <br />❑ PER SITE ❑ EACH ❑ January 1 6 Rn <br />eceived By Jar) <br />BILLING REMITTANCE <br />EXPLANATION DATE - DATE <br />— - i <br />w <br />Permit No <br />Rece,ved -by Date E ` :Receipt No. +PERMIT/SERVICES <br />. <br />APPLICANT—RETURN ALL COPIES TO: " NVIRONµEN7AL HEALTH <br />S ' <br />REMITTED <br />-t s <br />31 : ❑ July 1 8 Received By Juty 31 <br />REMIT <br />AMOUNT DUE CHECKED <br />1 AMOUNT <br />I I <br />air. ... <br />Is anDate Mailed Delivered <br />1601 E. HAZELTON AVE., P.O. Boa 2009 STOCKTON, CA 95201 -- <br />