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— Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. r <br /> APPLICATION <br /> (For Non-Transferable;Revocable, and Sus I.- Z- x <br /> SEPTAGE4W e I <br /> f;- R ENVIRONMENTAL HEALTH-PEAMITI� "�? <br /> LIQUID WASTE <br /> Application' hereby made to ca on business in the jurisdictional area of t%S..aan Joaquin Local Health District Q q <br /> Business Name (DBA) Address f" ztd -n • ! ��1� <br /> z Owner. _ Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a � ��� _ Emergency Telephone No. <br /> IL Business Telephone No. y <br /> i Contractor Licence No. .- <br /> Applicants Name (Print) l4it. V 5 Title -' pate `Z`�'^ 3 <br /> Please check Applicable Category (1-7)and Fill in the Required Information 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I <br /> For July 1, June 30, 19 'Disposal Sites - <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License Na. 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 /> v. <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 cation <br /> Test Date/Time ` <br /> 4. ANiTATION PERMIT ��` •.s; . , t <br /> Job Address/Location r 4 <br /> Owner ~Addres�s/� <br /> SEPTIC TANK 13-CESS OL EACHWG FIELD J EEPAGE PIT El PACKAGE PLAIJt (Its) <br /> ❑ TEMPORARY gNEW ❑ REPAIR 11 OTHER '• a <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> +vi i <br /> Type Construction Disposal Site <br /> No. of Ur its Equipment Storage/Cleaning Location(s) <br /> occatti`oon(s) <br /> i_ 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ; <br /> I - Where?Certified <br /> Operator Name <br /> Plant Location ~ 's s <br /> =- No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 ' <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> I' ❑ DRY CLEANING, Chemicals Used/Amount/Mo. " <br /> Nome owner orlicensedo"ni's9igliatur ,Mi <br /> ece : ?he fc:iowing:1 certify:il € :]uG rI"s?�rkC sine:vL fCr�:l�l it'ihisp£rl?l IsiS$uefi:vst�ll oiemployanype's'. <br /> In 5#1Gh Inannet:t5 to 13eGorre S"II)IBCt 30 :UritiY4Tr�b t:i,:ALn53titi73 iR'ha o- PH <br /> WS - <br /> Contractor's hiring or Buil-contracting sigr+ctLra csrtif':�s the . "1 certify that in the performance Oat the tvorkttor kvhich this;,ermll-is45sued,I-sh3H y <br />'i employ persons subject to workmari s competisa n latus of California' <br /> I hereby certify that I hav pr pared this application and that ttte work-w" a done'in accorda ce with-San.-Joaquin County <br /> ordinances, state laws, a s d reguiatio f the Sa quin Lo I alth Di ict.E t <br /> `s <br /> r � <br /> APPLICANT'S SIGNATURE X <br /> _ FOR DEPARTMENT USE ONLY <br /> I Fee Is Due: ❑ ANNLLY ❑'PER UNIT ❑ PER SITE. 11EACH E3 January 1 &Received By January 31 © July] &Received By July 37 <br /> UA <br /> ri5 ,REMIT § <br /> • BILLING REMITTANCE $ i AMOUNT DUE CHECKED a <br /> BASE EXPLANATIONS AMOUNT E <br /> 4. . DATE r DATE REMITTED x;a ;( <br /> FEE <br /> I LES5 <br /> �"-PRORAT-IDd" w' ' <br /> PLUS <br /> - -- <br /> PENALTY'«•.•«• J r <br /> OTHER <br /> OTHER i <br /> 17 <br /> i Received by Date Receipt Nv. Permit No. I uance ate Mailed Delivered <br /> 1501 E.HAZELTON AVE.,P.O.Box 2009 STDGKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ` <br />