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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) i <br /> 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 Dis#rict. _ , <br /> rn Business Name (DBA) Xo,,11f Sa Address A67 X. 't d7 llzyede5 !, b <br /> z Owner.... Address- <br /> j Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No.. '.� �"•`� �J w: Emergency Telephone-No, <br /> � _ £� <br /> Contractor Licence No. . Zep67 <br /> L Applicants Name (Print) Title R Date `s "�x <br /> Please check Applicable Category..(1-7) and.Fill in the Required Information :. t• ., "; w L r ,1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) F —4)For July 1,- - June 30, 19= Disposal Sites -' - <br /> Description(Make/Yr., Color) <br /> :Serial No. CAL. License No. CAL. License Renewal No. I <br /> Capacity Gal.,Weights &Measures No., i <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. 0 PERCOLATION TEST , <br /> R.S. or R.C.E. Name R,S. or R.C.E. No. <br /> Test Location ) Test Date/Time <br /> 4. 10 SANITATION PERMIT <br /> Job Address/Location _ !5'A6 3' .Sfl, -1/c Tay+� �� �'s cA <br /> Owner "t, Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT PACKAGE PLANT !+ <br /> ® PERMANENT TEMPORARY IN NEW El REPAIR ® OTHER -'0A4/05 <br /> 5. ElCHEMICAL'�TOILETS For July 1, June 30, 19 <br /> Type Construction Disposal Site,. <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name jWhere Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑'LAUNDRY For July 1;-June 30, 19 d LL <br /> SIZE Less Than 1,000 Sq. Ft.,- ❑ More Than 1,000 Sq. Ft. <br /> ❑ <br /> DRY CLEANING,Chemicals Used/Amount/Mo. <br /> Home olrvrercr 19cemrd a4enYs signatta!^44r?;f;3s i t� e';lot>ing:"I ce,rirf}+that it the perfrmanco of the1vork far which this permit is issued,I shall not employ any person ��rr <br /> in such manner a5 t0 becrim£SL�bject t0'KIOfi(!.?.;:5 C ^fps.15.tial!I:,;VS 01 Vaiifo nla_' <br /> Contractor's t�irEng or a-ro�rractir„ s> r, tare ca�tr<.:n the ioilowing: '•I cenify that in the performance of the work for which this permit is issued.I shall <br /> gmploy persons subject to wcorknlan's compensation lalr s of i:6lif0fnia." <br /> t <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, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X `u , <br /> FOR DEPARTMENT USE ONLY - <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 l July 1 &Received By July 31 <br /> _ : REMIT I <br /> BILLING REMITTANCE $ <br /> BASE ,I EXPLANATION DATE BATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS i <br /> . PENALTY' <br /> OTHER-- _ .�,1 r✓ - - - <br /> r l <br /> c OTHER <br /> _ _ <br /> Received by ate F Receipt No., ' - t'- Permit No "- - Issuance Date Mailed Delivered <br /> r APPLICANT—RETURN ALL COPIES-TO:.:s ENVIRONMENTAL HEALTH PERM IT/SERVICES-" 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />