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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ms— 89—(0` (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> A4RG�L G LIQUID WASTE .S V R. <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 /> a Owner kms`.=� FAaR:c-.,-\ 1. kE.'F tE_ Address <.% <br /> AYECA !95-n7-42 <br /> J Firm Partners, Addresses and Telephone Numbers �G724— <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) vYAL ER 9- <—Q1c3I Title C 1(1�.. Date 9 rLZ—�9 <br /> Please check Applicable Category(1-7)and Fill in the Required Information ZA <br /> 1. ❑ 4103 IAKM4PUMPER 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. ZI PERCOLATION TEST4i8( *,rTkEW fILPa �.r0 3(a — i a �� - '-SIJ L "L <br /> R.S. or R.C.E. Name iYPeli FE, R.S. or R.C.E. No. G rz� 14'14.84— <br /> Test Location 0h 1kirl- K`09,I1A 7tritLE MJF BIL'TAAH1r RD Test Date/Time-'L.IZIY.TiVE6&PV?*-PAtz;' {2flLrr_,_ n1V (0"5-'89 <br /> 4. ❑ SANITATION PERMIT ''14.23 VE-= n1F RE'E\(tz rk-f ,f - PRRC-0 -A'T1oed REAbil C- :<44 <br /> Job Address/Location 1c--(6"89 (l, 30— P1l01•>1 y FF IDM <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 Z <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 /> Homeowner or lioensod agent's signatrire certifieR the following:"t Certify that in the perfotTowe of the work for which this permit is issued.I shat I not employ any person <br /> in such manner as to become sublets to w0rkrrl!r's compensa�iee lbws of ca.ltomf;: <br /> Contractors hiring or sub-con:.aclir; signatun: certifies the following: I certify that m the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's compensation laws of Caiitornia." <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 r2}les and regulations <br /> ofof-the <br /> -San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE Xc �u/iJC if�7 t f v <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 �Q r .�.C.. 4 0 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER A <br /> Received by Dat6 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 />