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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Translerable, Revocable;and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH,PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to car on business in the jurisdictional area of t San Joaquin Local Health District <br /> H Business Name (DBA)n-�P114 Tz�.St•! 1►!S_ 1.�C�.. KAddress <br /> z Owner Address w ; <br /> J Firm Partners, Addresses and Telephone Numbers .. I <br /> aBusiness Telephone No. 44:901 "5)G4V`7 Emergency Telephone No. <br /> Contractor Licence No. . <br /> Applicants Name (Print} rl�)� y ;___ Title 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; j• af"sJune 30A9- - Disposal Sites - 11 <br /> Description-(Make/Yr., Color), - <br /> Serial Nd .s - 4-} € _-__ CAL. License No. f CAL. License Renewal No.` <br /> • Capacity, --, "� 'iGal., Weights & Measures No. <br /> r.V t f —K,I h`' I. t r- �t t r <br /> r qulpmeht`ParklrtZJ Address r <br /> 2. ❑ PUMPER YARD <br /> FonJuiy 1,;yY June 30, 19 <br /> No-of Vehicles Stored ��' <br /> No. of Chemical.*Iets Stored <br /> 3. 11PERCOLATION TEST ? K �' # <br /> R.S. or.R.C.E:.Name-- 3 R.S. or WC.E. Nod;iii ! <br /> T t L• cation` > t Test Date/Time <br /> 4. SANITATION PERMIT ( ° ° <br /> Job Address/Location <br /> ner p_—r- 4::IvND l�`i Mfr.C 1 Address <br /> e <br /> SEPTIC TANK (] CESSPOOL LEACHING FIELia'- ❑-..SEEPAGE PIT ❑ PACKAGE PLANT,. <br /> PERMANENT ❑ TEMPORARY I7 NEW XREPAIR ❑ 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) Az <br /> ) I, <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 � ` I : <br /> Operator Name WHere Certified', =r ( VVV <br /> Plant Location •. ) <br /> Plant Capa1'ty 'd . / _ / ( No._U/nits.Served� y-,a �` <br /> 7. ❑ LA U DRY For July 1, -June 30, 19 - • ; <br /> SIZE: ❑ Cess Than 1,000 Sq. Ft.,- ❑ More Than 1,000 Sq. Ft. 1 <br /> DAY,CLEANING, Chemicals Used/Amount/Mo. <br /> Hcrr{vo�vr,ern-tEce^eek Tonlzg;�nai:ureerwl.€i� #afoYnr:Rr' I e=t tib � � .F?nC ofthoynrkforavhid,this permit isissued,Ishallnotenployanyperscn <br /> If1iiCt�manrt2f$5 f0 bE'Ciile 3Ib?ect tp i�Utkt?7?11'S 4:OI1;i t:11icJ7ii.c..S !r 1::.,, a <br /> g9rate ntar's h;rin ar sur:ting sigratire r.ertif9es .I a Ydlowin :.t i certihy ihat in the)tetiorir:as;'i ci_ihe work for which this permit is issued,l shall' <br /> 6rf1p1o�pefsons subiec:to ti°rcrk,nan's compensation laws of Calif i6V iiia."-" <br /> I hereby certify that l have repared this application and that the work will be done in accord nce with San Joaquin County <br /> ordinances, state laws_, ant le and regulations 6f the 5 oaqu�HetricaAPPLICANT'S SIGNATURE X ' <br /> I <br /> ` f} FOR DEPARTMENT.USE,-ONLY_„..:....,.-• <br /> Feels Due: ❑ ANNUALLY 0 PER UNIT ❑ PER slk ❑ EACH ❑ January 1 &Received January 31 ❑ July t&Received By July 31 <br /> REMIT <br /> i <br /> BILLING REMITTANCE <br /> BASE °+tEXPLANA#IDN � , AMOUNT DUE CHECKED ;. <br /> DATEr +�.� DATE - REMITTED AMOUNT <br /> FEE . ' . <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> SI <br /> ,-OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered I <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES '1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> l <br />