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t <br /> 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 PERMITR1�C�Tv <br /> LIQUID WASTE #� <br /> Application i reby made a carrn business inrpe..lurisdictional area of tan aquin Local Health tri t. 11 <br /> Business Name (DBA) �%�/� �� Address__ `d:t T/T�+��.. <br /> i o Owner <br /> _ Address <br /> a k <br /> Firm Partners, Addresses and T�� Numbers <br /> a. Business Telephone No. y r F. yI <br /> Emergency Telephone No. <br /> Contractor Licence No. { <br /> -y 1 <br /> f_ �- f <br /> Applicants Name (Print) t-[�i p�• /lam!�LC�D a� ` n Title. y Date !� <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) N <br /> For July 1,...:. -..June 30,-19 Disposal,Sites <br /> Description(Make/Yr., Color). II <br /> Serial No. CAL. Licehse No. CAL. License Renewal No. <br /> Capacity iGal., Weights &iMeasures No. <br /> Equipment.Parking Address t - -- <br /> 2. ❑.PUMPER-YARD - <br /> For June 30, 19 <br /> No. ofe ehlcles Stored' <br /> No. of 04rnical,.Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name 4 R.S:'or R.C.E. No. <br /> Test L cation Test pate/Ti'm_ <br /> 4. SANITATION PERMIT �., <br /> Job Address/Location F_ c� 1 i <br /> O ner ajh" AfAW- ?W -- Address <br /> ►SEPTIC TANK ❑ CESSPOOL V- LEACHING FIELD ❑ SEEP_AGE PIT ❑ PACKAGE,P.LANT <br /> De <br /> PERMANENT ❑'TEMPORARY X:NEW � ? REPAIR ❑ OTHER 1 <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 I <br /> Plant Locatiorr a t s e <br /> Plant Capacity No. units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,J ❑ More Than 1,000 Sq. F't: > u Y <br /> ❑ DRY%§ANING Cpemicals Used/Amount/Mo <br /> o>Antettcr:rensedCgort'ssign$turaaert[#iesti,efatlo,anrg;'FIC�rt }th i}-in the I t ti t„tjl `• <br /> ill SilCtEnlann4r35tC�IJ9CSir51e5YIt3jCCttC4'YC[IFC1ail.acel.11Sensatiorr.a;�sof;Ci4'th !ir performansevfthewcrkfa ; i.,f�,�,s�errtiltisissue'"3 ,;ul:r:�te: �loy2ry,.rr " <br /> Contractor's t7irin9 or cuo-coretraCtin9_S*-gust+erg: ccrtlfies the fo"I.rn'virt 4 1 <br /> e�VIG-Y Persons subject to wurhr€ian's camper<satiorl'avrs off&lif�rnia' i+ '` I Ccrtify that ii1 11L pesudralan.,C„of-the vloree ler u:hirh`•l;is Pes 1i;is i�suEd,!st?all ,efl <br /> I liereb%w,Nrtify that I have prepared this application and tfiat the work will be done Jqaccord nce with Joaquin County <br /> ordinances, state laws, ah'd,vules and regula4! ns of the n_,Joaquin Local Health Distcict.A: t "`I <br /> : . .N•.., ., <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY f ❑ PER UNIT ❑ PER SITZ=b �`❑ EACH ❑January 1 &Received By January 31*• ❑ July 1 &Received By July'31 <br /> 3 i <br /> ' REMIT 4 <br /> f BASE - 1 EXPLANATION ; BILLING REMITTANCE AMOUNT DUE CHECKED <br /> 77 DATE DATE_ REMITTED AMOUNT � <br /> FEE ;t -. ,... '� �:�:r..-,. ri. �we...w.w. .s•�.t.--7. . yr«w ' ... �,�. ..�__ -,.--.., .i �1I <br /> LESSq { # 1 <br /> PRORATIONr .- 3• ,+.". <br /> PLUS t } <br /> PENALTY .3 .. <br /> OTHER t ► <br /> OTHER - ` <br /> Received 4y Date Ate,Receipt No.'--_) o Permit No Issuance Date Mailed Delivered <br /> APPLICANTRETURN LL COPIES To, ENVIRONMENTAL MEA�7ii PERMIT/SERVICES" '1601 E.HAZELTON AVE.;P.p.Box 2009 STOCKTON,CA 95201all <br />