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<br /> ' Applications Will Be Processed When Submitted Properly Completed, Be Sure To Sign a pp Ica Io
<br /> APPLICATION
<br /> (For Nan-Transferable, Revocable,and Suspendable) SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> r LIQUID WASTE
<br /> ' Appl ica ' n is hereiby m e to carryon usine s i he j dictional area of th arlyJoaq Local H—}e�Ith Distric
<br /> y Busine ame (D Al Address[[ ���• ��
<br /> z Owne Address
<br /> a
<br /> II Firm Partners, Addresses and Teleph a Numbers
<br /> t a Business Telephone No. lQ� Emergency Telephone No.
<br /> 4
<br /> Contractor Licence No. l
<br /> Title Date
<br /> L Applicants Name (Print)-."`
<br /> Please check Applicable'Cat ry (1-7) and Fill i e Required tnformatian r
<br /> 1. ❑,;PUMPER_'VEHICLE.PERMIT REGISTRATION (FOR EACH VEHICLE) �J�1
<br /> ' *Ju_ 30, Disposal Sites
<br /> For July 1, ne 19
<br /> Description,(Make/YT_, Color)
<br /> Serial No. ` CAL. License No. CAL. License Renewal No_____,L
<br /> k Capacity Gal., Weights &Measures No.
<br /> Equipment Park ing`Address
<br /> 2. _❑ PUMPER YARD,-
<br /> ARD
<br /> C _
<br /> For July 1, June 30.19
<br /> No. of-Vehicles.Slored;
<br /> No,
<br /> 'of- heroical Toilets Stored -
<br /> 3. ❑,PERCOLATION TESTr
<br /> `
<br /> R.S.or R.C.E:-No.
<br /> A.S. or R.C.E. Name
<br /> t Test Location
<br /> Nest Date/Time
<br /> 4. W SANITATION PERMIT
<br /> Job Addre / ocationQ� '
<br /> O�w�r e.rj-4 �=-u .JL ,-,� ?��Adds Q 6-5-q
<br /> Ie' / 11SEPTIC TANK 13UP ®S
<br /> CESSPOOL ACHING,FIELD EEPAGE PIT El PACKAGE PLANT
<br /> PERMANENT TEMPORARY ❑ NEW ®REPAIR 0 OT
<br /> l� HER 1+
<br /> ' S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 k 'r, ,
<br /> T
<br /> t Type Construction Disposal Site
<br /> y No. of Units Equipment Storage/Cleaning Location(s)
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June�30, 19 —�
<br /> Where Certified
<br /> Operator Name
<br /> r Plant Location ;
<br /> I ` - .� No. Units Served
<br /> Plant Capacity - . _ - .,
<br /> 7. ❑ LAUNDRY—For July 1, --June 30, 19 'x _ '-
<br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft!
<br /> 1
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. T
<br /> Home ow-wer licensed agent's signature eertMesthe twlowtng:"I certify that In the performance of the`work forwhich,Mls pemn-Is issued,I shalt not emplay asey perm-
<br /> In such manner as to become subject to workman's compensation laws of California."
<br /> r Contractor's hiring or sub-centraeting signature certifies the f�a+towing; '1 certify that in the performance_of.the work for whfch this:pertnit is issued,k shall' ,
<br /> employ persons subject to workman's compensation laws of Caliiforrija.' , ----.�.. *
<br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County�� }
<br /> ordinances, state laws, nd rules a re lations of the San Joaquin Local Health District,
<br /> APPLICANT'S SIGNATURE X - �-- — ---
<br /> t � f
<br /> i FOR DEPARTMENT USE ONLY
<br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑January T&Received By Sanuary 31 ❑ July 1 &Received By July 31
<br /> < 1 REMIT
<br /> BILLING REMITTANCE `'_} SCHECKED
<br /> E
<br /> BASE EXPLANATION DATE
<br /> OUE ,.
<br /> - pATE ,�` DATE REMITTED I AMOUNT _
<br /> FEE \
<br /> LESS a
<br /> PRORATION
<br /> PLUS
<br /> PENALTY. '
<br /> OTHER
<br /> i
<br /> OTHER Y
<br /> €�� ssuance ate Mailed Delivered
<br /> Received by,x Date_ „ __ Receipt No. Permit No.' M _
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - - 1601 E.HAZELTONyAVVE.,.,PP.Box 20139 STOC TO ,,CCA 95241
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