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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />PPF--MZC_V_ W4 ` APPLICATION <br /> BpRt a (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 a <br /> z Owner UEL3 RZ Zd N r' ✓.EN _/al&i Address lCa 4- <br /> I <br /> rA <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) ><vA;,zr E-R _'2:7 in Title I f`1 `"2 Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information ti5f _ <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) MKi`�f�4 � a �c�1j3 - 4i5�j <br /> Low 5�'4-tD <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 .1" <br /> 3. 0 PERCOLATION TEST448 M liTC_H�VSc A/�j�l�r!! yet F`AJPr fit_Nec•.1) 1:45 <br /> R.S. or R.C.E. Name '�A�-t�� C-IJR-7-t R.S. or R.C.E. No. C>- 11 fit- -T HL X12',DO <br /> Test Location �� Art/ ?AL1 Test Date/Timer.1-k`H'ilVE2W PAk: f-(CL.acag ILSc 5Li <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location 9- 9- Ir-50— f4,x31,: <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 Q <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 7)_ <br /> Operator Name Where Certified ml <br /> Plant Location a <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 /> Homeownerorlicensedagent'seigaaha?carts+resthefollovriag:'hcert)fythatinMeperfotinanceoftheworkferwhichthispermit isissued,I;haI;nrtcmployarr/perst <br /> In such manner as to becomes i ct to worxmt:n's compensation laws of California:' <br /> Contractor's hiriN or sub-cosltracting a:9.1stwe certifies tow -follow rig: 1 Certify that in the partormarice of the work for whi.! ";s parm'.i i�;:;_r�,i sraJ <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 r les and regulations off the.San Joaquin Local Health District. r � e <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY � / '/7 <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & eceived By January 31 ❑ July 1&Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION A <br /> DATE DATE REMITTED MOUNT DUE CHECKED <br /> AMOUNT <br /> - l50 �+G �S lSO`- <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <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 />