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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> a APPLICATION <br /> C / (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> / o i✓ ENVIRONMENTAL HEALTH PERMIT p <br /> ?co <br /> '� �IgyIWAS (� {(�T� Lo t) fid`TSE �$Cl�l 1lf D� ��� <br /> Application is'TiLmade fo'c�rry on bus n�ss� a u71�dlCtiona bPth�Sari Joaquin Locafl;T'4� riott <br /> Gy Business Name (DBA) ztd ss Y I rr <br /> aOwner �-- m Address x 5 Q- a - CA <br /> J Firm Partners, o9dresses and Telephone Number t' `' : A lY1 ST LAS Z S-T <br /> aBusiness Telephone No. 0"T n1 Emergency Telephone No. � <br /> Contractor Licence No. T — CA <br /> L Applicants Name (Print) F L Zc Ce— Title Q Date d 0 <br /> D(Please check Applicable Category (1-7) and Fill in the Required Information <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 /> 2. ❑ PUMPER YARD -7 Zl7 4-0AX V`W <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. ol Chemical Toilets Stored <br /> 3. PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER Com, <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 �I <br /> Operator Name Where Certified re <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 /> ki <br /> HouchmanOwner orlicensed tobeco gee►t'saignstursoe►t;fk+athnfory�,,,s••et"Ir fv�h,�r�rr,��g ft,�anrrofttteworktarwhtrhthis erm!ti§is u d.lch ! <br /> In such manner as to become subject to war};s�1?a'r•cc:rrle;►satK.. P � n I not employ Lny per$ <br /> Contractor's hiring or 3ub-contractin3 .4gnrt yre cnnfi.• <br /> employ persons subject to workman's ewrnponsation laws of California. I'l-u''' "''°' Jt'.s issued,I shah <br /> I hereby certify that I have prepared application and that tty work will be done in accordance with San Joaquin County <br /> ordinances, state laws, n rules d gul tions f e San JoahlLin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> a <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 AMOUNT <br /> FEE ,V 1Pe� `V /`ZJp [ G a0 C D C,6D /77 / <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> O <br /> Recei y 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 />