|
Applications Will Be Processed When Submitted Properly Completed. BeSureToSign IneAppneauan.
<br /> APPLICATION
<br /> (For Non-Transferable;Revocable;and Suspendable) SEPTAGF
<br /> ENVIRONMENTAL HEALTH,PERMIT
<br /> ` .- LIQUID WASTE+
<br /> i Application is hereby made to carry on business in the jurisdictional area of the San JoaquinLoca!Health District :.,. r
<br /> Address_ tr a 1U1. Tc.A
<br /> rn Business Name (DBA) v
<br /> Address ter. pi , . .
<br /> z Owner _ .. Lw, ,
<br /> Firm Partners, Address s and Telephone Numbers > 3
<br /> iiEmergency Telephone No.
<br /> a Busmess.Telephone No. :a
<br /> Contractor Licence No. ` - G.
<br /> Title Date
<br /> L Applicants Name (Print) a�,.. .
<br /> Please check Applicable Category,(1-7.) and Fill in the Required Informatlons tf r *a> 0 O _ #,:=
<br /> ,s"
<br /> 1. C] PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 4
<br /> June.30, 19 _. . _:- ' _Disposal Sites
<br /> For-July 1, - - ,
<br /> i Description(Make/Yr., Color)
<br /> F Serial No. CAL, License No. CAL. License Renewal No.
<br /> Capacity Gal.,Weights& Measures No.
<br /> r
<br /> Equipment Parking Address
<br /> 2. ❑ PUMPER YARD;
<br /> For July 1, June 30, 19
<br /> I No. of Vehicles Stored `No. of Chemical Toilets Stored w
<br /> 3. 11PERCOLATION TEST
<br /> 'c R.S. or R.C.E.No. '
<br /> R.S. or R.C.E. Name
<br /> Test Location Test Date/Time
<br /> I
<br /> 4. -0 SANITATION PERMIT- E : ) ► �G '' a
<br /> Job Address/Location
<br /> Owner a ` Address l"
<br /> SEPTIC TANK ❑CESSPOOL ❑:LEACHING FIELDe ❑ SEEPAGE PIT ❑ PACKAGE PLANT
<br /> PERMANENT , ❑ TEMPORARY ETNEWk? ❑ £REPA�IR• ❑ OTHER
<br /> 5. 11 CHEMICAL TOILETS~ For July 1,-June 30, 19'
<br /> Type Construction - - - Disposal Site ( -
<br /> �.
<br /> No. of Units Equipment Storage/,lflsaning;�ocat�ionO^ J `
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 } t
<br /> � Where Certified. -
<br /> Operator Name f
<br /> Plant Location .
<br /> Planl Capacity No. Units,
<br /> Served
<br /> 7. ❑ LAUNDRY For Jul 1, -June 30,.19s
<br /> ;SIZE: ❑ Less Than 1,000 Sq. Ft., ElMorThan Sq,Ft.
<br /> F
<br /> ❑ DRY CLEZING;•Chemicals Used/Amount/Mo. ;
<br /> Horneotivnarorlicensedegent'ssignatureeertiife)gthefeltowi�,"lcer�ifylratinthe performanceof.thework Inrwhichthispermit isissueA;lshallnotemployanypersnn
<br /> in succi manner as to become subject t�%,orkmarl's ceropeRsatiG%i3v'A of Calll3r:Iia ' '
<br /> Contractor's uts
<br /> hiring de b -contra hind sig-sture CcWfieS U�c,fofiovving: `i certify that tit the;)erfarmance of the work for which this per�it is issued.!shall
<br /> employ persons subject to workman's compensation laws of Callforaia."l ) f
<br /> I hereby certify that.] have prepared this application and that the work will be done in'accordance with San Joaquin County
<br /> ordinances, state laws, and,rules and r gulati s of-the-Sara-Joaquin Local Health District.
<br /> APPLICANT'S SIGNATURE X
<br /> FOR.DEPARTMENT USE ONLY i
<br /> t _
<br /> ee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE '[1 EACH E❑January 1 &Received By January 31 { ❑ July 1 &Received By July 31
<br /> i REMIT
<br /> t BILLING REMITTANCE $ _-,�,_,,,, .AMOUNT DUE CHECKED
<br /> BASE .FE%PLANATJON�.: .DATE '�-- DATE REMITTED € AMOUNT
<br /> � o
<br /> ' C t
<br /> FEE-
<br /> ' LESS. J/
<br /> PRORATION - "' - t
<br /> PLUS -_ .,..�--+Y- - ...� •.: f. .� s� . .r S..---.
<br /> .,....,.,.-PENALTY_. .-- ----� - ._- -.
<br /> OTHER
<br /> OTHER
<br /> ate
<br /> Received by Date Receipt NoPermit No Is ante Mailed Delivered rr
<br /> 'APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 4601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201
<br /> s
<br />
|