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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 hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District. <br /> Address %2�s E` 119i0PT S7d � <br /> �Business Name (DBA) � - ,� 4 <br /> z OwnerAddress <br /> Q 1.1j%". r ,Y u = 'l..i -— , Tw ,..r'Jim vj 6w -1- <br /> J Firm Partners, Addresses and Telephone Numbers _ 1, <br /> a Business Tele hone No. — Emergency Telephone No. " <br /> 1 Contractor Licence No. . <br /> Applicants Name (Print) i Titley Date <br /> Please check Applicable Category 0-7)-and Fillin-theRequired Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1; .-.June 30;19 Disposai,Sites. <br /> Description(Make/Yr., Color) <br /> :Serial No. CAL. Llcense No. CAL. License Renewal No. <br /> ' 4 , t <br /> 'Capacity Gal., Weights & Measures„,No. <br /> }Equipment Parking Address # <br /> '2. ❑ PUMPER YARD <br /> 'For July 1, June 30, 19 - 's <br /> ,No. of Vehicles Stored '' <br /> No. of Chemical Toilets Stored i <br /> '3. ❑ PERCOLATION:TEST �, R.S.or R.C.E. No. <br /> iR.S. or R.C.E. Name E <br /> Test Location Rr - Test Date/Time f } <br /> r <br /> r4. SANITATION�.,ERMIT <br /> i n,1i j'Y14 - <br /> Job Address/Locat o <br /> Owoer -�- - Address Sy 9 <br /> ❑•SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT E s <br /> {❑ PERMANENT ❑TEMPORARY NEW REPAIR <br /> ❑ OTHER <br /> 5. ❑ CHEMICAL-TOILETS For July 1, -June 30, 19 <br /> ,511.0. <br /> ~ �'k "” ' Dis osal Site � <br /> Type Construction p w t <br /> No. of Units ) L n Equipment Storage/Cleaning Locatlon(s) {� I <br /> .6. ❑ PACKAGE TREATMENT PLANT For July 1, -Junet30, 19 t <br /> (Operator <br /> I Name -_Where Certified t <br /> - ,. <br /> Plant Location <br /> ]Plant Capacity No. its Served <br /> 7. ❑ LAUNDRY For-July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1;fl00 8q. Ft !) ❑ More�Than 1,000 Sq-Ft. <br /> i❑ DRY CLEANING, Chemicals Used/Amount/Mo. # } r� t <br /> Home owner or ficenaedegent'9 signature certifiestW fngowir g:,..T:ertity that irtihe performarlceof the work forvthich this permit is issued 11 shall not erttploy any person <br /> in-such rnanner a5 to become gWect t0,w0rkmaa=5 Compensation lacus"o!Catitornia.•' [[ <br /> Contraetar`s hiring or s6blontracii%i signature c''ertifies the•foffowing, "i certify that in the perlomlance of the work for which thislpermd is issued,I shall <br /> firttplaypersons subject to worlcymyan's compensation iaws.of California.,, <br /> I hereby certify�that`t'have priparediothis-appliC tion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,trttl rules and regulations: a oaquin Local Health District. k <br /> `APPLICANT'S SIGNATURE X ... <br /> a � i <br /> A _ 'OR DEPARTMENT USE ONLY -. = <br /> 1 Fee IS Due:0 ANNUALLY '❑ PER UN1TjFA. ❑ ;PER SITE -❑ EACH ❑ January 1 &Received By January 31 El July 1 &Received By July 31 ' <br /> REMIT . <br /> �"- BILLING - REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE. DATE. REMITTED € <br /> I if A AMOUNT <br /> FEE <br /> t - I. <br /> LESS 7 <br /> PRORATION } }} <br /> PLUS <br /> PENALTY ..,wr- talT <br /> OTHEROTHER -Received by Date Receipt No- Permit No. ' Issuance Dat Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES '1601 E.HAZELTON P.O.Sox 2009 STOCKTON,CA 95261 <br /> n <br />