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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applic ion is here made to carryon business in the jurisdictional area of thgjSan Jo uin Local Health D' trice <br /> Business Name (DBA 2 r.0 �vJ ddress �• -1 <br /> z Own -L Address •�, C <br /> 9 <br /> 0 Firm Partners, Addresses an Tel hone Numbers <br /> EL Business Telephone No. • �' / U s Emergency Telephone No. <br /> Contractor Licence No. - �C_G <br /> LApplicants Name (Print) ' C Title _ Date•:�N �gt� �3 <br /> Please check Applicable Cate ory (1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> �. June5 <br /> For July 1, �June 3�1� Disposal Sites <br /> Description(Makean;C19186 <br /> Serial No. CAL. License No. CAL. License Renewal No. {� <br /> vv.s�•ti1�.3. <br /> Capacity Ural.,Weights & Measures No. <br /> Equlpr�nA kariring >tcldress r �C 1 <br /> I <br /> 2.. P. EFS YA <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored r1 t <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 /> Test Location Test Date/Time + <br /> 4. 2 SANITATION PERMIT <br /> Job Addre /Coca ' n <br /> Owr • -Qr <br /> Address � <br /> L� SEPTIC TANK CESSPOOL 2 LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT a(j <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 • \r <br /> Operator Name Where Certified } ' <br /> Plant Location . " <br /> Plant Capacity No. Units Served °t <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 /> Horne owner Qrlicensed aaent'seictnatcln <br /> in such manner as to becr^r ca.tt}iosti,ef�lawir,g "lcertifythatin pertortrraceaftltework for whielrthjspermitisisSued.EShall not emplayanlpert <br /> ,�6, cs tc v,rrl I„ .i s t nlr;,sn.Satlo l taws::+.Caliternia: '• <br /> Corrt*y Pef s hiring oil<,'ork m rfb c f1", ris,�1an d c:erx:f7Gs tftE raltowing; 'T-certi y t t in the perfomtance�f the work for which this permit is issued, shall <br /> I <br /> employ persflrts suhje�t iv warkrnaq"s ttlmtrens;tinn laws otCalllwnia.' 1{Jl <br /> 'r� <br /> I hereby certify that I have prepared this application and that the work wig beydone in accordance with San Joaquin County <br /> ordinances, state laws, d rules and regulations of the San,Jgaquin Local�Health District. <br /> :fes <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 1 ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED 0 <br /> AMOUNT <br /> FEE J( <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3_ 8 _ 6 <br /> Received by Date Receipt No Permit No. l4suancle Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTO�N AVE.,�P.Q.�Box 2009 STOCKTON,CA 95201 <br />