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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. APPLICATION (For Non-Transferable, Revocable,and Suspendable) SEPTAGF ENVIRONMENTAL HEALTH PERMIT LIQUID WASTE Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District OF Business Name (DBA) Address a Owner �1 Or, D-,-r-3,A Address Z2CJ �(�(I��nGJ_T'RAc,y C A S57 4Q J Firm Partners, Addresses and Telephone Numbers Mpq') Q. Business Telephone No. Emergency Telephone No. Contractor Licence No. 4: —k L Applicants Name (Print) WAL�L2 'E' C-0RI-lS Title r till—t►��iKEj�� Date V Please check Applicable Category (1-7) and Fill in the Required Information 418 MAZA I 95TYrz4-c) 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) &un" PlAcr4t-- (2a9) 946 1950 For July 1, June 30, 19 Disposal Sites HOM.P, PtAONG (7L09) 9S(c,15 4459 Description(Make/Yr., Color) Serial No. . _ CAL. License No. CAL. License Renewal No. Capacity Gal., Weights & Measures No. Equipment Parking Address 2. ❑ PUMPER YARD For July 1, June 30, 19 No. of Vehicles Stored No. of Chemical Toilets Stored 3. R PERCOLATION TEST KS a�3�7"%2 (4ca74- W. CAt`11raizt4"f, A4E O£,) T"C-Y,Ct^. e�ree s ! I C SIlMM R.C.E. Name YYf1CU 7--ri S Rlttlow R.C.E. No. C.I` i 1p;a4— Test Location 4C04 W. CAUR2F4 61 A ANE - NCY C A Test Date/Time 4 4. ❑ SANITATION PERMIT �� 9 Job Address/Location Owner Address ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 Type Construction _ Disposal Site No. of Units Equipment Storage/Cleaning Location(s) 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Operator Name Where Certified Plant Location _ Plant Capacity No. Units Served 7. ❑ LAUNDRY For July 1, -June 30, 19 SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. ❑ DRY CLEANING, Chemicals Used/Amount/Mo. Homeowner or licensed agent's signatttro certiftns the following:"I certify that in the per!=,ance at the work for which this permit is issued,l shall not employ any person in such manner as to become subject to,work;rru1's c-:llmon..r,tiaa Laws ct California' Contractor's hiring or sub-conract:nq sib tete cort.9los t«e 'ollotivirig: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to wcrknalYs co.opens<:ti,r1 laws of Caiifui nia:' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regul ions of the Joaquin Local Health District. APPLICANT'S SIGNATURE X �'J FOR DEPARTMENT USE ONLY Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED n L ; AMOUNT FEE r tI ��y�rOrJ LESS PRORATION PLUS v ' PENALTY r�� rJ OTHER OTHER Received by Date Receipt No. Permit No Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201