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M"PWApplicationsWill 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 M5- S - -73 <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DBA) Address <br /> eOwner MAZY 51�5P�kI Address R0._BOX II?2)L-ppTGAL_tF<5Pt"IA 9-,2.40 <br /> J Firm Partners, Addresses and Telephone Numbers(zog)333-Z(gles <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) WA1--TFfZ E cur-t-i-, Title GIYIL Es4GIkEEP- Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information 4-Ig MATt"MEW PLAZA <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I_(�I CAL% (75,2A"0 <br /> For July 1, June 30, 19 Disposal Sites (Zo9) 3(08 - 4-159 <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. X PERCOLATION TEST M(s— $�—7 3 bIvlt] 20 gcQt 04-r`0 2 PnSZxARcEL =( o AcfzE <br /> R.S. or R.C.E. Name NVA trR � <br /> , CuCu -rit f�R.C.E. No. 1158. PARC- <br /> -Tli� t'19 od Ac IRE <br /> Test Location i ?,C% JAHANT ROAD Test Date/Time - t 2-S' wC;Viij <br /> AcAMP,0CA,L(MRt,IIA 95226 P0EcOA,tz1r i�0�� $-II-�3-] ASO MtiK� (7EwTATNir, <br /> 4. 13 SANITATION PERMIT d$,E3LVATta+�S v'' g-IZ-g� <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 or Ncensed agent•a s�'gnattere certmen the fonowir,p:"I certity that in the performance of the work for which this permit is issued,l shall not employ any person <br /> in such manner as to become subject to workman's compensation;arcs of Califatrc� <br /> Controaor•s hiring or sub-contrecting signature certifies the fonowin9: "1 certify that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's compensation 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 rules and regulati0 S of the Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X �h <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 /> -- AMOUNT <br /> FEE GO-Cie <br /> SO <br /> . 60 <br /> LESS <br /> PRORATION <br /> PLUS �(1 <br /> PENALTY <br /> OTHER NJ <br /> OTHER <br /> 8 t0 g^1 <br /> Received 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 />