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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) SEPTAG <br /> ENVIRONMENTAD WASTE M5— <br /> PERMIT M5— 9 ' <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District 1 <br /> Business Name (DBA) Address <br /> a Owner_JIl RicK Address Ml '1n[EM GRAPCTLiNE ROAD AcYI CA, <br /> J Firm Partners, Addresses and Telephone Numbers 9s39IG <br /> a. boom sse Telephone No. Emergency Telephone No. —_ <br /> Contractor Licence No. <br /> a Applicants Name (Print)W l-=fM E GuGZTIS Title CiYiL-EtAGI WE£Q Date Pq - <br /> Please check Applicable Category (1-7) and Fill in the Required Information C• E.-* 1) <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) om, <br /> For July 1, _ _ June 30, 19 _ Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal , Weights & Measures No. <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. ;R PERCOLATION TEST MS 9 �—Lj i Q^QC�L_ 1 I•l OAC/ PAW-I-- z t• - /'�C� TC TP4-- c- <br /> R.C.E. Name W#,I_TE2 1;� C:I-j V,'Tt5 PFSF r Fl.C E. N . <br /> Test Location iµE Test Date/Time <br /> 4. 11 SANITATION PERMIT Tf2Ac y,cam. 953 C, 2-A91 izs^u,gG5 <br /> Job Address/Location -- cJfd aRy <br /> Owner _ Address •o0 — <br /> D SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ 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) _ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <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 /> Home owner or 1!cen sed agent's signature certMersthe following:"I certify that in the performance of the work fm which this permit is issued.I shall not employ any person <br /> in such manner�,.?,he:nme subiect io wo?i;maii:,ccm,ensation lattis o!California.' <br /> Contractor's hung or �u:ua-.;iJ^re. signature. cer.ifies t?,f- ioliowing: "i certify that in the performance of the work for which this permit is issued,I shall <br /> empliYY »i ��tQFYai H yid � ;Rpr{trdl0�Gr8tios'and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations off-thee-San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE. <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 2 �-•u� -Ci.I 'oC" <br /> LESS <br /> PRORATION <br /> PLUS �� ISG, es <br /> PENALTY LJ _ <br /> OTHER t3 4 it <br /> OTHER <br /> Received by Da Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />