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f pI <br /> ications Will Be [o essed' en Submitted Properly Completed. Be Sure To Sign The Application. <br /> r AUG APPLICATION <br /> (For Non-Transferable, Revocable and Suspendable) SEPTAGE <br /> .A1,1' JiDAhU'0N LO IRONMENTAL HEALTH PERMIT <br /> HEALTH DIS—i PXT LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin-LocakHealth District ., <br /> r Business N me (DBA) Address <br /> z Owner .lir CLJr-YSF.� — / idress <br /> a <br /> Fico ,.Partners, Addresses and Telephone Nlu�mbers <br /> 03 4_7 <br /> CL <br /> BwT=4 telephone No. � �_7 �Z Emergency Tel No. FL/7.— <br /> CL <br /> Contractor Licence No. s <br /> L Applicants Name (Print) -- .Title Date 4 <br /> Please check Applicable Category(1-7)and Fill in the Required Information r } <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 /> y 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S. or R.C.E. No. <br /> t Test Location ' Test Date/Time <br /> I <br /> 4.;4 SANITATION PERMIT <br /> Job Address/Location d O <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL k LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 11 NEW ❑ REPAIR OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 �*fi� „ n a <br /> Type Construction Disposal Site r �•`^.�j <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 /> j SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> e <br /> t <br /> L H6R1COW1181'Otf1GEQSSad8q®!It'SSj[]�yatyfrereCti'til;S(41wTOISpyyjR�:�•�nertlfythat ititheperformanceofitleworkfaiwbirhthis permitisissued.lsh-All not employ artypers,n r <br /> 1 in sL,0.manner as!q became suh;eci tG•work.,ran's i ftpe:nation Iasis of <br /> 6 Gontr tar's !siring or si:gnat»�e ra:"i::e� the iaL'otjjnrU: "l certify t,'at in Ifte perfOrmarlL>;Of the 1IUfk for w111Ch IITIS permit t5 ieSFJe«,i shall <br /> employ perso,,ls So'ujc"t to wotktnan's cumrer, :;;io,1 lati Ji ral ,,"ia," <br /> I herebycertif that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> y PP <br /> ordinances, state laws, and rules and re,ulatiors 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 /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE f,5 <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY A - <br /> tp OTHER _ <br /> OTHER <br /> Received by Date Receipt No Permit No. Issuance Oat ailed Delivered r� <br /> r APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES .1,601 E.HAZELTON A .BOY 2x09 STDCKTON,CA 95261- <br />