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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 her bypa a tp carry on business in the jurisdictional area of the San Joaquin Local Healtqr�District <br /> y Business Name (DBA) S C -r 4 � SrAddress 44'9 CongyodO A vto <br /> a Owner LOn t F 2 Address P. Or Fox 9 7 <br /> J Firm Partners, Addresses and Telephone Numbers �� 9 411) <br /> a. Business Telephone No. q43—Z0-21 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) S i f Title Date 6 2-1- 9,0 <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. 0 PERCOLATION TEST MS – 9 0 – 133 <br /> R.S. or R.C.E. Name i9pbert -fl-&or R.C.E. No. )73,91 <br /> Test Location b 5A el� S- marbo4y AvadTest 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 /> 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 C q�t�4IG Chemicals Used/Amount/Mo. <br /> - wnbrorticensedegent'ssignature"rtiflosthe f0H0vW t�yr <br /> in such manner as to become suhiect to workman's COmpensation�WB oofCa(ifornia.'theperfomtanceoft!tr'work►nrwhiehthis permit isissued,ishatinotem o an <br /> Contractor's hiring or sub-cantreetir' asa k,i!,i Cues the toNowing. ..f Certify that the performance of the work for which this pernrit is issued, shalt on <br /> employ persons suJject to workla�n's ccrnae 1,a;i;.,1,,;ws 4f 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, n�Arules and <br /> /reegula Ions 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> C�+ / ` AMOUNT <br /> FEE e0o �+� (i-�-7'�O f0 ^� �C7 -0� Pic) <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Jm <br /> Re eive 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.Boz 2009 STOCKTON,CA 95201 <br />