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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> t ` 1 (For Non-Transferabfe, Revocable,and Suspendable) SEPTAGE <br /> 1 ENVIRONMENTAL HEALTH PERMIT <br /> uQuio WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> w Business Name (DBA) Address <br /> aOwner rS .,. - C�f � Address ; <br /> Firm Partners,Addresses and Telephone Numbers <br /> Business Telephone No. Emergency Telephone No. �3d <br /> Contractor Licence No. / l <br /> LApplicants Name (Print) J� v� P6TP?�"' Title y- '�! � Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information . <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) } �• <br /> For July 1, June 30, 1,9 - Disposal Sites <br /> Description(Make/Yr., Color) I <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Ga1%�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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Tet ation R Test Date/Time +' <br /> 4. VX SANITATION PERMIT r •i - _.. ,. T-- _ _ <br /> Job Address/Location 1 �1.� u r �` �AA " <br /> Owner 1 <br /> Address .a <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD , EEPAGE PIT 11 PACKAGE PLANT <br /> El PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ,,, ❑ OTHER <br /> .: <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 of <br /> V <br /> Type Construction - # `" i , 4D 1.� d <br /> Disposal Site fi <br /> No. of Units t Equipment Storage/Cleaning Location(s) I <br /> 6. ❑ PACKAGE TREATMENT'PLANT For July 1, -June 30, 19 r_ <br /> Operator Name ' Where Certified <br /> Plant Location : <br /> Plant Capacity -I <br /> ` No��Units Served''`s <br /> 7. ❑ LAUNDRY For July 1, -'June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq: Ft.: ❑ More Than 1,000 Sq. Ft. <br /> re Than <br /> ❑ DRY CLEANING, Chemicals Used/Amouht/Mo'-' <br /> HemeawReror licensed , --� <br /> agent'ssittfattrreaertifieetti�follo`wegp;"ICertl�yth3tiRtffe <br /> in sash manner as to becamesutsjerttowarAR�n'scorrlyensationtawsgfC>tf+fthatDWermanceofthewm*forwhichthispetmitisissued,1shallnotemployanyperson <br /> Contr3cto►'s hirirr� nr sub�ontr�ttlng sigf�ture Cerfiff" the f fl i <br /> ploy per$ <br /> alts subject to workman's Comperlsallon taws of 0ahi omir," ` .1 certify that in the psfforlttan4e of the work 10f which this permit is issued,I shall i <br /> I hereby certify that I have prepared this application and-that the work will be done in accordance with San Joaquin County r <br /> ordinances , state laws, and rules and regulations of ars J in Local Health Distr' t <br /> APPLICANT'S SIGNATURE X <br /> a <br /> I �'-T { FOR DEPARTMENT U O Y <br /> Fee Is Due:.❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ ' <br /> { - - ry 1 &Received By January 31 ❑ July 1 &Received By July 34 <br /> BASE EXPLANATION j BILLING I R ANC $ REMIT <br /> J DATE - TE I REMITTED AMOUNT DUE CHECKED <br /> FEE <br /> p0 AMOUNT <br /> �., - � - �. .f. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY --- i• - <br /> � <br /> OTHER 6 . ; <br /> ,OTHER ` <br /> Receive y Vate Receipt No. Permit No. - } <br /> Issuance Date Maile Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ` <br /> } 1601 E.HA2ELTON AVE.,P.O. 2009 STOCKTON,CA 95201 <br /> 14 ` <br /> s r� <br />