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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) <br /> SEPTAGE 1 i <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 /> yBusiness Name (DBA) 4- Address <br /> a Owner. /_'14A1gL5S' Z .27�-Al6f --- — Address —� W �,L P4 cam, K2 i GA. - 3G�-9z9 s' <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone NO.'; L Emergency Telephone No. j <br /> Contractor Licence No. - 4 <br /> LApplicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill-in the Required Information <br /> l' <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. X'PERCOLATI ON TE' <br /> ST <br /> S. o R.C.E. Name v .c144_�4� R.S.or R.C.E. No. <br /> Test Location -74 �� -3Z T-6 7 to/Time ) <br /> 4. ❑ SANITATION PERMIT f��,y 0 Q —7 9 U <br /> Job Address/Location <br /> Owner ess v <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. LJ, <br /> Home owner or licensed ng3nt'ss';;ma ,,e.e;ewic s the fonowing:1 certIfythal in.the perform ance of the mnkfor which this permit is issued.I shall not employ any person <br /> in such manner as to become suu;cct to v,Bl k;n6i:'s cru l ensatiarr lat, at G2fito:(11c <br /> Contractor's hinny or sA-ra r:rac::rF; :;igki"ire certMes tha following: "I certify that in,lie performance of the Work for which this permit is issued.I sha17 <br /> employ persons subycct to rror icaiai s conipensat',,n 1�,Ws of California." <br /> r <br /> 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. jl <br /> APPLICANT'S SIGNATURE X <br /> 4 J <br /> FOR DEPARTMENT USE ONLY <br /> r. <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED i <br /> AMOUNT <br /> FEE C�Q <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY * - <br /> c <br /> OTHER <br /> OTHER �. <br /> v M J <br /> ReceiveZr-byl D to - Receipt No. Permit N Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HATELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />