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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) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application s hereb made to Carryo business in the jurisdictional area of the San Joaquin Local Health District <br /> '�r ,Qi� c1119'>�' Addresser <br /> A"iness Name (DBA) <br /> z Owner Address <br /> JFirm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title �� Date <br /> Please check Applicable Category(1-7)and Fill in the Required I ormation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) t <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL.License No. CAL.License�lenewal No. <br /> Capacity Gal.,Weights&Measures No. <br /> f <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD i <br /> For July Y;^ June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored 4-J <br /> 3. ❑ 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. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner ..f900r Ig �s1/ Address <br /> .® SEPTIC TANK ❑ CESSPOOL LEACHING FIELD PIT ❑ PACKAGE PLANT _ <br /> PERMANENT ❑ TEMPORARY OrNEW REPAIR ❑ OTHER '; <br /> ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> e Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. Q PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location �a <br /> r <br /> ,Plant Capacity No. Units Served C <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 _ <br /> SIZE: ❑ Less Than-1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> 1p� }�&FA1fP_E &e a }�+arf RR32i1F1 EQF4lf(�Rflip 40f1 31q ,'y6aNif llidtlttlhll(?Ptf9#t Ali�q61t!?@?5r 1`ktorwhich tlllspermit Islssued,Ishall not employ any person <br /> ltk10§Fnn?pe;tsllmi "Ig6h11'siM.H;ll t <br /> 0 i jirr:§ hi�ityg,Rf $uh coriit�cti{+g'ss$ahttl=e cot ball'111d W.1ov.:nrg; `t certify brat jn-lh�performance of the work for vthich this permit is Issued,l shall <br /> ttlpl4}�persdns`sub}'esct to vrortlllaii s`compensation lases 01 a lifurri,a.' I, _k <br /> I hereby certify that I have prepared this application and that the work will be done iri accordance with San Joaquin County <br /> ordinances,state laws,and ancLreg latio of the, a Joaquin Health District >.• <br /> f i <br /> APPLICANT'S SIGNATURE X <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> .Fee IS D4@: ❑ ANNUALLY [3 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received 8y July 31 - <br /> a t <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTA E $ AMOUNTpUE CHECKED <br /> — DATE D REMITTED <br /> AMOUNT <br /> FEE, 4 a <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY -+� 4, iF •r C ti ' <br /> OTHERS Y tip.. �.t`•: �� "� E a`> a:y+ �.• ` 1 <br /> I ti� <br /> OTHER <br /> 1 <br /> S 3 t <br /> Received by- Date Receipt No. Permit No. Istuancelvale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES"' -`1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />