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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 4 APPLICATION <br /> (For Nan-Transferable, Revocable, and Suspendable) SEPTAGE ' <br /> ' ENVIRONMENTAL HEALTH PERMIT <br /> �! LIQUID WASTE Y R <br /> Application is hereby made to carry on business in the.jurisdictional area of the San Joaquin Local.Health District <br /> FBusiness Name (DBA)RA 'F_ AIMLS145; 1500S,X SAddressR 0 <br /> i Owner " -Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> Q. Business Telephone No. C� _9420-72 ,Emergency Telephone No <br /> Contractor Licence No. ' on_r <br /> Applicants Name (Print) 'T N ! Tltle � {�I Date <br /> Please check Applicable Category,(1-7)and.Fill in the Required Information 4 , t, , M' <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 A', Disposal Sites. - - -- <br /> Description(Make/Yr., Color) _ <br /> Serial No. I CAL. License No. CAL. License Renewal No. <br /> f <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address I I <br /> 2. ❑ PUMPER YARD s <br /> For July 1, June 30, 19 11- <br /> No. <br /> tNo. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST p <br /> R.S. or R.C.E. Name r �_ R.S. or R.C.E. No. <br /> I Test Location .Test Date/Time <br /> 4. SANITATION PERMIT `� " <br /> Job Address/Location ���� Q© • �I L 99 <br /> Owner V Address M <br /> J�.SEPTIC TANK ❑ CESSPOOL r ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ` ❑ PERMANENT ❑ TEMPORARY ❑ NEW } ❑ REPAIR ❑ OTHER 4 <br /> f 3. ❑ CHEMICAL TOILETS For July 1, -June 3-0, 19'. �• <br /> i Type Construction x Disposal Site <br /> 'No. of Units "'G :Equipment Storage/Cleaning Locations) r— <br /> . <br /> 6. ❑ PACKAGE TREATMENT PLANT.' For July.1, June 30, 19 <br /> ' Operator Name �� t Where Certified <br /> Plant Location i s %` .T- <br /> Plant Capacity ; * _ � .* - No. Units Served <br /> .7. ❑ LAUNDRY For July 1; -June 30, 19 <br /> ' # <br /> SIZE: ❑ Less Than 1,000 Sq.'.Ft., 0 More Than 1,000 Sq..Ft"' <br /> ❑ DRh LEANING Chert icals y§qd/Ariiount/Mo:r ,'- <br /> e Be agents=t;,n;ttrrac�rtit; etraf�tEnw4rtcr:"I^2rti;;[f�'(: �epe*tCrma.nr.ea:timworklorfhictthispesmitisissued,ishallnotesrplayanyper "r <br /> in such manner as to became subjcd to workman's compensatlmn taws of Calilorni�-_ <br /> Contractor's hiring or sub-,:ohtracting Signature certifies the :oltawing: "I certify that in the performance o1 the work for which this permit is issued,.I shall <br /> , employ persons subject to workman's compensation laws of Cafifornia." <br /> I 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 reguI ns of the San Joaquin LocalVealth District. i <br /> APPLICANT'S SIGNATURE ,a , <br /> I' FOR DEPARTMENT USE ONLY - ` <br /> Fee Is Due: ❑ ANNUALLY .':I ❑ PER UNIT, <br /> El SITE ❑ EACH .❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> i - REMIT <br /> BILLING REMITTANCE $ <br /> t AMOUNT CHECKED <br /> BASE EXPLANATION <br /> - DATE - DATE :1 REMIT - AMOUNT- -` <br /> FEE �. IN" it �' <br /> LESS <br /> PRORATION ! [ <br /> a .r..+.PLUS,....�...,,r..:.,,;, '.- Y" .... ......r...,......M.u.:w..,� �»...» <br /> PENALTYOTHER <br /> OTHER <br /> I �D- o- <br /> _ Received by Date Receipt No. Permit No. Iss ance Date ailed Delivered. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - ' 1601 E.HAZEL'TON AVE.,P.O.Box 2009 STOCKTON,CA 95201- <br /> ii <br />