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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 is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) Address <br /> OwnerMR ROBTE-M M,"141AS Address x 27 so Vahl A%__� et'i <br /> Firm Partners, Addresses and Telephone Numbers k 2-co9i) E�3P�- 74-G-3 CA K? <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. _ <br /> Applicants Name (Print) WALTER, C ,�tS Title c►lrll_. EN(' lil,4 Z. Date Z-AS5 91 _ <br /> Please check Applicable Category (1-7) and Fill in the Required Information 4(F MA rrVAr=W PI' <br /> _ <br /> �7-A t-0V��� A V SxNS <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 4tSg <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. ;&PERCOLATION TEST 4v0j <br /> Px:S=or R.C.E. Name VVilii S_V'R_-T'l" -R;3w&r R.C.E. No. [( <br /> Test Location 173L'ZSn 'VAt�. AL,%.�t4 Rt> Test Date/Time lx-< 19-9 1 At <br /> 4. ❑ SANITATION PERMIT�v�A� ��cA 9 :1J -ND11V�yS Y+ ED -L�-9) AM <br /> Job Address/Location <br /> Owner Address <br /> ❑ 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 orlicensed agent's signsture certifies the following:"1 Certify that in the perfonnaneeofthe work for which this permit is issued,I shall not employ any perscr <br /> to such manner as to become subject to workman's compensaflon taws nt Ca.i±orRia ' <br /> Contractor's Kiri" or sub-contracting rignsturo certifi.s the following: "1 certify that in the performance of the work for which this permit is issued,t shaft <br /> employ persons subject to workman's compunsation laws 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 fules and regulations of the-San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <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 <br /> q REMITTED AMOUNT <br /> FEE O ( Z 1 Iz, -0 <br /> LESS �J <br /> PRORATION -- <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Recery eff by 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.Box 2009 STOCKTON,CA 95201 <br />