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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 /> ,C � u Address 12 � • 94,!U 4 ST <br /> Business Name (DBA) a <br /> x Owner_ Address i <br /> a 21 <br /> - <br /> J Firm Partners, Addresses and/Telephone Numbers <br /> C6 <br /> Business Telephone No. ��� -�/�7� Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) s • o-D _ Title Date_ o10:ne?F. Z— . <br /> Y- ` <br /> Please check Applicable Category(1-7) and Fill in the Required Intormation A s <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) t <br /> i <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. ❑ PERCOLATION TEST T a ' <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test(Lcation I Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location �lGTdIIJ <br /> Owner _ A&D �_� + � _ -,Address 47 ' <br /> SEPTIC TANK ''❑ CESSPOOL 1. LEACHING FIELD' .SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENTw, =P TEMPORARY.-> y NEW,,- .," ,❑ REPAIR ❑ OTHER w <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ob <br /> Type ConstructionDisposal Site <br /> No. of Units i Equipment Storage/Cleaning Locations) <br /> 6. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name ' Where Certified <br /> Plant Location <br /> Plant Capacity <br /> A 1 No. Units Served ' All <br /> 7. ❑ LAUNDRY For.July 1, -June 30, 19 - <br /> SIZE: ❑ Less Than 1,000 Sq, Ft.,,�­❑-'More .han 1,000 Sq. Ft, <br /> 11 DRY CLEANING, Chemicals Used/Amount/Mo. r <br /> i <br /> Roma owner wfiwi 341 - <br /> sedagrat•ssigM tUM cert{;-tha#otto.ring:"l certify that in the performance ofthe worlifor which this permit is issutd.l shal4 not employ any per;n! <br /> in such manner as to becomo subject t4 workmart=ARsatiott laws of Catifomt a." <br /> Contnctor'e fi'n'd OF sub-contracting signaum 06t6fiea the TOROwing: i certity tfti t ip the psriormance of the work far which this permit is issued.l shalt ,.—4)ealplof persons subject to workman's c0mpei►sati3ti lawrs califoinw, _ ► + <br /> 3. w T` <br /> I hereby certify that I,have preparedvthis�application and that the'work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules d regulations•of the Sa Joaquin ai Health District. <br /> APPLICANT'S SIGNATURE <br /> VA <br /> FOR DEPARTMENT USE ONLY <br /> ' e--'Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> �,.j.. REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ 41 AMOUNT DUE CHECKED <br /> DATE DATE... REMI - AMOUNT <br /> O <br /> FEE - - - <br /> e LESS <br /> PRORATIONPLUS <br /> a.. PENALTY <br /> OTHER .:c <br /> OTHER / /� [1(�l■�� { <br /> Received by Date Receipt No. Permit No. Issuance a Mailed I Delivered <br /> APPLICANT=RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON A E.,P.O.Box'2009 STOCKTON,CA 95201 <br /> i s <br />