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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION siEP L_Y <br /> t (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to c rry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) aN p%dZZ11Address�23 W. ELM ST,Lf�f _r= 135,17-4� <br /> Owner Pte`[ PY& `A Address?2'b W EL k4 ST i1Dlg5�24� <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. + 2 0 —CGCG I Q1 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title G. c Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <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. CK PERCOLATION TEST <br /> R.S. o R.C.E. Name P/A-ZZQ R.S. orf,�E, No. __H& <br /> Test Location 20f W. JAW,&N7 FV F12. GZ . Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ 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 licensed agent's signature comfles"foilowing-1certifythatinthepert^rmanceoftheworkforwhichthispermitisissued.Is.�allnotemployanyperson <br /> in such manner as to become Sebject to workman's cgmpensaticn lave;rlf Ca!if;,-nia <br /> Contractor's hiring or sub-contracting eignatue cer±;::es the following: ..1 certify that in the performance of the work for which this;ermit is issued,1 shall <br /> employ persons subject to workman's compensatiaa L ws of California." <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 <br /> E I _p <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> /� AMOUNT <br /> FEE `Vbr �� ( 318 eL) Z <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I1!i /-1 :/ �9 3 - <br /> Re ei y Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 95201 <br />