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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable;Revocaible�, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT ." <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joa uin Local Health Districts <br /> FBusiness Name (DBA) Address ' <br /> _ . . 1 <br /> z,Owner � 16 - r. ,Address - <br /> J Firm Partners, Addresses and Tele <br /> ph ne Numbers <br /> . <br /> m Business Telephone No.. t Emergency Telephone No. <br /> A Contractor Licence No. .. % <br /> Applicants Name (Print) c- x - -Title —{a 4 pate <br /> Please check Applicable Category (1-7)and Fill in the Required Information # r <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) xyy s' s"•,. <br /> For July t,. . 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 r <br /> No. of Vehicles Stored <br /> No..of Chemical Toilets Stored ( } <br /> 3. ❑ PERCOLATION TEST t I <br /> R.S. or R.C.E. Name t R.S. or R.C.E. No. + <br /> Test Location t f ! Test Date/Time . f <br /> 4. -`SANITATION PERMIT -- . � <br /> Job Address/Location ,, <br /> Owner �J � � _1 4-417,.4'6t :.,ry { Address 4 <br /> SEPTIC TANK ❑ CESSPOOL- - t LEA6HING FIELD ❑ SEEPAGE PIT ❑-PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19', - <br /> Type Construction 3 Disposal SitQ . N <br /> ' .No. of Units Equipment Stor'aoe/Cleaning Location(s) �* <br /> 6. ❑ PACKAGE TREATMENT PLANT'For Julytl_,___"ie°30^191 <br /> Operator Name Where Certified j <br /> Plant Location <br /> Plant Capacity <br /> No. Units Served <br /> 7. ❑ LAUNDRY-For July 1, -June 30-19 4} <br /> SIZE: ❑ Less-Than 1;000 Sq. Ft,, ❑ More Tharf 1,000 Sq. Ft. i� « <br /> 3. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Flornea wnerorlicensedagert'.1sipnetureeeriKieathefgIlZtingr"I tertify titin the perfArntancr n1l the work forwhicfithfq permit Is issued,Ish6li not employ any persort <br /> in such manner as to becon,,e 5'Jblectt r ,i <br /> Contractor's hinny ar..-ub-cnrlt,nrt.rly-a slnntu:a cehif esl,he fo4owing: ,"'l certify.that in the performance of the work for whichihis permit is issued,l shall <br /> employ persons subject to workman s componsation laws of California." <br /> F <br /> ! hereby certify thatvl_have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,-state laws, and rules and reg-Ula 'ons of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ` <br /> ! FOR DEPARTMENt USE ONLY,-7- S.— <br /> Fee <br /> amFee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE1-1EACH El January 1 8.Received By January 31. EJJufy 1 8 Received By July 31 <br /> _ REMIT <br /> BASE - EXPLANATION BILLING _ REMITTANCE $ AMOUNT DtJE CHECKED <br /> r - - y...____,� '. DATE. �. DATE ,REMITTED - - . . `� AMOUNT <br /> FEEcd <br /> LESS <br /> PRORATION <br /> - i <br /> PLUS I <br /> PENALTY - . <br /> OTHEfj,,, -.e,...► -�.�.,,,werr..� j�a,ew _ '"�' r _ .. <br /> �7� r <br /> Received by Date Receipt No. Permit No. k Issuance Rate Mailed Delivered <br /> - APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - IaOVE.HAZELTON AVE.;P.O.Sox 2009 STOCKTON,-CA 95201 I <br /> nl <br />