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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> — - /� APPLICATION <br /> ,,• 'z. 7" gf--j :or Non-Transferable, Revocable, and Suspendar SEPTAGE <br /> i ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE _()-7 <br /> Application is h reby made to carry on business in the jurisdictional area of the San Joaquin Local Health Di trict t <br /> Business Name (DBA). � � Q, Address S lee,�L.�� <br /> aOwner y Address <br /> Firm Partners, Addresses and Telephone Numbers - ~ <br /> aBusiness Telephone No.���Q�-�-`��- ^'�S� �-Emergency Telephone No. <br /> Contractor Licence No. <br /> a Biu./ 'J 9sncrr Date "' 4-e,r <br /> Applicants Name (Print) �� G. Title,_ �, <br /> Please check Applicable Category (1-7) and Fill in the Required Information LZ 41787- e&6 <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 /> ­ <br /> 2.2. C1PUMPER YARD <br /> For July 1, June 30, 19 <br /> aof ehicles StoredCh mica)Toilets Stored <br /> P COLATION TEST <br /> C.E. Name � f R.C.E. No. <br /> � � . <br /> Test Location Test Date/Time 9'G�S-9Ot <br /> 4. ❑ SANITATION PERMIT - ?` <br /> I <br /> Job Address/Location _ <br /> Owner Address 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. <br /> dame owner or licensed agent's nignatulre cert#igs the fotlnwinq!"!rettfffr drat if'thenerfarma€tce of 4howork f or which this permit Is issued,i shalt not employ any person <br /> in such manner as to become subject fa work,m:m�cegmpE.1saOaN tat r-it(:;1 tfnjnt2 ' <br /> -- Contrattar's hiting ar. sutl-contrarting sig rattm, a ortwa3 the fof awing: '"I certify that in the performartce of the work for which this permit is issued,I shall <br /> employ persons subject to workmatl's comperlsatfori laws 01 Califarnia," <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, an rules and regulations of the San Joaquin Local Hea_Ith District, <br /> APPLICANT'S SIGNATURE.. G �� <br /> bio 9erder� h Termsrk � R- 25 �tO f_. t.-S <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE E ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 R Received By July 31 <br /> REMIT <br /> BASE EXPLANATION <br /> BILLING REMITTANCE $ <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> 1. {r pQAMOUNT <br /> FEE ""'7 lI.R1 '� f�L `� f f� ° ��'CY�. L <3Z <br /> LESS <br /> PRORATION " <br /> PLUS <br /> PENALTY <br /> OTHER �r <br /> OTHER - -� <br /> Received b Date tReceipt No rmit Nd. - 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 /> r <br />