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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> PARCEL MAP#DC-Bt-- 5 (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> DkvELLiµG C Lvs�EiZ APPL1c ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> �Pr c,gr�-1 1 Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rn v 1-iENPoe -41 A -4 Address <br /> a Owner SAM ESPR IG4t,4 k-), cY c- <br /> E Address 1 ►>3 L1N 4>LA�F Z"F2A �S3L- <br /> -1 <br /> J Firm Partners, Addresses and Telephone Numbers PHo;IE (?by) f335 - 4 87 <br /> Q. Business Telephone No. Emergency Telephone No. <br /> a <br /> Contractor Licence No. <br /> Applicants Name (Print) y i__l E q E C- 1 Title c"MIL Et4C=%B=�R Date OGToBE'R Ito 19E3co <br /> p�. �P�,L-�•d c�A �5Z4bPlease check check Applicable Ca�gory� ra^ ill m he equire �n orma ion ��,�NESS FNoµE C2ar)) 94f3-79�b <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) NOMI PHDNJE <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. I$ PERCOLATION TEST PA9,C El. MAP DC "8(0'S)Z WE41 j M G C_L.,ST G'? APPL1,CA-T 1 ot-► <br /> -P^6--or R.C.E. NarDe WNL—"TE RS^ef R.C.E. No. i 15je�4- <br /> Test Location C R OF -THE INTtSZstc,TioW OF' Test Date/Time SQAK- i0lZa/See READ ic, 8(,- .-TE14TA-TiVE <br /> 4. ❑ SANITATION PERMIT "RRAL HOl lI_ci)/ ANb LARcP PoADS �7i3s�9 C' z�:iC ` : bA-TF_ <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 orlicensed agent's Tiara are enrCfies the following:"I certify that In the performance of the work for which this permit is issued.I shall not employ any person <br /> in such manner as to become s0ject t.,w,a,kman's unpansptioa fawn of Cal;lorrsia. <br /> Contractor's hiring or sub-c,ntracting s°3nature certifies the following: "1 certify that in the performance of the work for which this permit is issued,l shall <br /> employ persons subject to workulan's compeasabcn lays 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 regulations of the SanJoaquinLocal 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEErN 1W, <br /> S O <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -��CA <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.Boz 2009 STOCKTON,CA 95201 <br />