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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 Suspenda_.e) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE ' <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> District � <br /> .F. Business Name (DBA) g,- %V - Address } <br /> z Owner + , Address ^ <br /> J Firm Partners, Addresse ans d Telephone Numbers_ z V ,_ F, t <br /> CL Business Telephone No. Emergency Telephone No. <br /> Contractor licence No. <br /> Applicants Name(Print) �" le a Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information= <br /> _,:4, <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 1 <br />. , -2._-0 PUMPER YARD *.. <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored 3 <br /> No. of Chemical Toilets Stored <br /> 3. )4 PERCOLATION TEST + j <br /> R.S. or R.C.E. Name —Ig rJ <br /> i R.S. or R.C.E. No. ✓ 12 <br /> Test Location r• -test Date/Time <br /> 4. ❑ SANITATION PERMIT*g0'31 Lt,�d� C� ,',52 Ie r iQ�.l i) <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 . _V` <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 1 No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 y <br /> :SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Hmnowneroritce*rsedagsnt'ssfpes certif isOwfulloying:"IW thMIntflePeftrmameoftheworkforwhichdNspermitisissued,IShallnotemployanyperson <br /> in such manner as to becofRt sub, to wwo i'�mrf z competetion laws of California." <br /> Contrectur'a ging or sub-c*Wr*cnng wgnature ce tdies dw !MW_ V; '!ceRtfy nod it:the performance of the work ter which this permit is Issued,I Shal l <br /> employ persons subject to workman s compensation laws otCalitttrnia. <br /> I'hereby certify that I h6e'prepared this'apiplication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and les and re ulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X14 <br /> R i - t FOR DEPARTMENT USE ONLY.. - <br /> _�`Fee Is Due: ❑ ANNUALLY' []'PER UNIT ❑PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July i & kved By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED . <br /> DATE DATE REMITTED AMOUNT <br /> AMOUNT <br /> FEE 57 <br /> 0 `U <br /> LESS <br /> PRORATION - - - - - - - <br /> PLUS <br /> PENALTY i <br /> OTHER13 <br /> OTHER - - - - <br /> 'Eu <br /> Received by Date 3' =Receipt No, Permit No. Issuance Date Mailed Delivered- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 --STOCKTON,CA 95201 / <br /> A <br />