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Applications ations Will Be Processed When Submitted Properly Completed. Be sure toaicjii i ^rr••— � *., Y�
<br /> APPLICATION
<br />, l_ - (For Non-Transterable, R(ivocable,and Suspendable) SEPTAGE u
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LiQula WASTE y
<br /> �Applic n is h�reb made to carry on bu In s int a jurisdictional area s the S oaq Local Health District
<br /> ,.
<br /> Address
<br /> F Busine Name (DBA Address
<br /> aOwne ...
<br /> u Firm Partners, Addresses and Tele hone tubers Emergency Telephone No.
<br /> 0.L business Telephone NO.. L '
<br /> a . . � 7
<br /> Contractor Licence No, Date
<br /> Title
<br /> a
<br /> ApplicantsjName (Pr rit), • .k , .' , Q} F
<br /> -,. k' s Ff n the Required Information. 1"
<br /> Please check Applicable r9ory(1_7)and
<br /> 1: �'Pl1ilAPER'YhtICLE,PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> ♦ t rr June.30 19 - t. =Disposal Sites t
<br /> fp..De�cription(Make/Yr.,COIOr)� - CAL. License No. CAL. License Renewal No.'�#
<br /> Serial Nc- I
<br /> Capacity= Gal.,Weights &Measures No.
<br /> rEquipment Parking,Address t
<br /> 2.- 1PUMP6-YARD G f
<br /> t IFor July 1, June 30, 19 i
<br /> NO. of Vehicles Stored
<br /> ' ,No. Of Chemical Toilets Stored
<br /> )3- ❑ PERCOLATION TEST R.S. or R.C.E.No,
<br /> In
<br /> or R.C.E. Name Test Date/Time
<br /> Test,.,,L,,O��C tion
<br /> r
<br /> q• W SANITATION PERMIT/
<br /> `
<br /> Job Ad i /t ocati n Z
<br /> Address '
<br /> Owner ❑ PACKAGE PLANT !` 7n
<br /> Owner 1&<EACHING FIELD r SEEPAGE PIT �;;� �, V A
<br /> VW'SEPTIC TANK ❑ CESSPOOL TEMPORARY W ❑ OTHER t _
<br /> ��,, ' ❑ EMPORAR ® NEW 11 REPAIR
<br /> 11 ERMANENT _ !„ - - ,._ -�
<br /> "13
<br /> �5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19
<br /> Disposal Site
<br /> ,Type Con
<br /> `No-of Units Equipment Storage/Cleaning Location(s) r �.
<br /> ❑ PACKAGE TREATMENT PLANT For July 1,-Jun
<br /> g Where:Certifisd
<br /> 40perator"Name !�^
<br /> Plant Location - ` _ i
<br /> No, Units Served
<br /> %Plant Capacity a i �" -•� j€ .
<br /> 7: ❑ LAUNDRY For.July 1, -June 30, 19
<br /> Less
<br /> Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq- Ft. \
<br /> •SIZES- '❑ - -
<br /> '❑.DRY GLEANING, Chemicals UsedlAmounUMo.
<br /> 1 4Home: owner orurensPdagent's signnturecertifies the 1`1011 certifythatin the Pe..omance of the work t4whichthis permit isissued,I$hallnot employ any person
<br /> 4 -l'w such manner as to become subject to workman s cc^pellsatiol+laws of Califorrip.',
<br /> }
<br /> contractor's Hiring or say-cmetra�tlrg sig.atury GGrtitie:: ti'M fcrllawing: `+Certil;•f let:n 11 tl e,perfoEl.i iiSrE of the work for which this permit is issued,i shall
<br /> employ persons subject tU v.nrknian'sirnpensation lases of Gatiloria-'
<br /> i I hereby certify that I have prepared this application and that the work Abe-'done in accordance with San Joaquin County
<br /> C ordinances, state laws, and r es and regul io Of the San Joaquin Local Health,District.\
<br /> APPLICANT'S SIGNATUREX ", 3
<br /> _ FOR DEPARTMENT USE ON1=Y y
<br /> I ' '" 1 Jul 1 &,Received By July 31
<br /> f � ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Rec` ed ByJanuary 31 � y REMIT
<br /> ;v
<br /> —.Fee Is Due: ❑ ANNUALLY CHEckED
<br /> ` BILLING REMITTANCE $ AMOUNT DUE w
<br /> '+T BASE EXPLANATION DATE DATE /REMI.TED AMOUNT
<br /> .e
<br /> FEE a `
<br /> LESS
<br /> PRORATION
<br /> I PLUS
<br /> J PENALTY -
<br /> 1 ' r
<br /> OTHER
<br /> OTHER -
<br /> "t isnce Date Mailed Delivered
<br /> su
<br /> Receipt No. Permit No.
<br /> Received by 1601 E.HAZELTON AVE.;P.O. ox 2449' STOCKTON,CA 95241
<br /> "APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES DA 1 ,A� 45
<br /> AIr„ t>n
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