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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 /> Application is hereby madeto carU on business in the jurisdictional area of the San Joaqui Local H�jalth Distrl t <br /> rn Business ame (DBA) O 1LAS 6 V d Lly u S1 Address 6_40 <br /> (nJf. ^-13 /A)p'� <br /> i Owner /AFO A �li�"A'� I!a1 O Q om4 Address � Fr 6 D .O- X O �.f n -� <br /> a <br /> Firm Partners, Addresses and Tele hone Numbers <br /> aBusiness Telephone No. $ � .Emergency Telephone No. E- <br /> 11 Contractor Licence No. .ry <br /> L Applicants Name (Print) .D A.FFti iJDu'--V Title <br /> 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 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. KPERCOLATION TFft$T IV <br /> R.S. or R.C.E. Name K L,p A/ JLz4E.0, � A-�&O'• R.S.or R.C.E. No. <br /> Test Location ,!IS 0 J"­rA1 D "1 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 <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 orlicansed agent's signature enr!if;asthe following:"I cor,ify that in theperformance of the work far which this permit is Issued,I shall not employ any person <br /> in such manner as to become subject to v:orkrlan's compensation;aws sf California.' <br /> Contractors hiring or sub-contracting, signature ceriffles the following: 'I certify.that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's compensation laws 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 (13 <br /> ordinances, state laws, and rljles and re ulati s of t San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> sQ G� <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 /> FEE a / <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER p <br /> O — <br /> R ed by Date Receipt No. Permit No. Issuance Date Mailed Daily <br /> PPLICANT—gETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STf <br />