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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign.The-Application. ° <br /> APPLICATIONf' --f - <br /> ., (For Non-Transferable, Revocable,and Suspendable) ,vF .-, <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH:PERMIT <br /> LIQUID WASTE` <br /> Application is here`r�Iade to carrn lysine s in the jurisdictional area of JbPSan 4aquin Local Health District f� <br /> h Business Name (DBA} ., #F/�1,e� 4- `P �7d��C . 1�` C Add ress'f o <br /> a Owner t j Address <br /> s " T , <br /> Firm Partners, Addresses and Telephone NumbersCL <br /> _ T <br /> Business Telephone No. UVa4n-CV1n0-7 Emergency Telephone No, <br /> Contractor Licence No. <br /> Applicants Name (Print) t Title Date Ito--..��-�� <br /> Please check Applicable Category,(1-7) and Fill in the Required'lnformation <br /> 1. ❑ PUMPER VEHICLE PERMITREGISTRATION (FOR EACH VEHICLE) 1 <br /> For July 1, - June 30,19- <br /> 0, 19 - . 'i _ _ Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial NoCAL. License No. wt CAL. License Renewal No. t <br /> Capacity Gal., Weights &Measures.NbS "i } <br /> Equipment Parking Address f A <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19ti•.- o- �►�°Y- ��- Y---r : � <br /> No. of Vehicles Stored <br /> ;No. of Chemical Toilets Stored! <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Nom. <br /> �i-Jet Lf cation Test Date/Time - <br /> 4. SANITATION PERMIT ! <br /> Job Address/Location <br /> r_ <br /> gnerp_L-4LlTG.t E ' �t1J4 FZ L� AddressETIC`TANK �'❑ CESSPOdLA'� ! ❑_ LEACHING FIELD ❑ SEEPAGE PIT ❑ PA KAGE PLANT <br /> ERMANENTY.1�❑-TEMPOFIARY � '.❑'NEWREPAIR <br /> ❑ OTHER'iQ" <br /> i �: <br /> 5. ❑ CHEMICAL TOILETS For July 1,--June 30, 19 �' 1 <br /> Type Construction Disposal Site �Y <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30 19 ,y (� <br /> Operator Name Where Certified < <br /> Plant Location <br /> Plant Capacity No, Units Served <br /> 7. Cl L)AUNDRY ' For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq: Ft., ❑ More Than 1,000 Sq. Ft, <br /> ' F,HT1 <br /> ❑ DRY CLEANING,~Chemicals Used/Amount/Mo. <br /> hhl3 'R1IsftaitIT1UtEPpIOyaTprS.- <br /> rr, <br /> IarWrt's^iGnn:sr^ h ^ <br /> in suc© <br /> manner as i0 become SUI3j°CI t0 1'%pin: a .. {� <br /> Contractor's hiring or sub•cortr:trtg s <br /> inrrrstL:s ni rc,. Iww.n .. ;1;- ...•:p iii '' trl,�fu iC�Sbls�ersa:ki5 iSsu[r,I <br /> employ persons subject to werkman S comp:naatl61 la'k la' of�uiii 7l!ilu. # T" <br /> I hereby certify that I have epared this application and t the work ill be done in accordance with San Joaquin County <br /> ordinances, state laws, an les nd regulati s of the 5 aqui c He h District. # * ; <br /> r <br /> APPLICANT'S SIGNATUREX <br /> ..,FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 CReceived By July 31 <br /> - ._ _..—,___VI- - REMIT <br /> TANCE $ i ! <br /> BASE EXPLANATIONBILLING EMITS. AMOUNT DUE CHECKED <br /> , DATE S;DATE ., ;REMITTED AMOUNT <br /> FEE .a. -,a. .� , F m <br /> LESS` € � ^. Uf <br /> PR ATION- -- <br /> PLUS <br /> PENALTY <br /> OTHER s i <br /> OTHER , s - = x{ r <br /> LO <br /> Received by Date Receipt No, Permit No. Issu nr ate-), Mailed Delivered <br /> _- APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HAZECTO E.•P.O.Box 2009 STOCKTON.CA 95201 <br />