|
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. .
<br /> APPLICATION
<br /> F (For Non-Transferable, Revoceible,fand Suspendable) SEPTAGF
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE
<br /> Appl ica n is he;ebyjmaclto carry on busine i the,ju 'sdictional area of the s�Joaqu Local Health Distric
<br /> rBusiness Name (DBA TAddress r --
<br /> z Owne Address
<br /> a -. ,� .. .. ,_
<br /> J Firm Partners, Addresses and Telephone Numbers F _
<br /> CL Business Telephone No. �Q �� V Emergency Telephone.No.
<br /> Contractor Licence No. L�
<br /> Applicants Name.(Print) Title Date ! z� 9
<br /> r,,._�?, ,u. -+u'i'.f'� i` '`q� y 4v Li...xwt it:It+�iYV crrw -
<br /> ,-Please check Applicable C'at ory (1-7)and Fil the Requiredantormation
<br /> b . _
<br /> _,�1. .❑..PJJMPER.VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> IFar July 1,- `June 30,19, - _ Disposal Sites__
<br /> 'Description(MakeYr., Color)Y',- - _
<br /> Serial NO. ; CAL. License No. CAL. License Renewal No.
<br /> Capacity Gal.;Weights & Measures-No. -
<br /> Equipment Parking Address ' 1
<br /> 2. ❑ PUMPER YARD
<br /> For July 1, June 30, 19 r
<br /> No. of Vehicles Stored
<br /> No. of Chemical Toilets Stored + `
<br /> )
<br /> 3. ❑ PERCOLATION TEST Y �. _
<br /> R.S. or R.C.E."Name R.S. or R.C.E. No. I
<br /> Test Location Test Date/Time
<br /> 4. SANITATION PERIT "# ►"
<br /> Job Add res /Location
<br /> Owner. Address —�
<br /> ❑
<br /> SEPTIC-TANK;.=❑...CESSPOO.L,,,�.�.C]„LEACHING.FIELD,_Q-3EEP_AGE P.IT_.4-0 PACKAGE PLANT
<br /> GO'-PERMANENT # ❑ TEMPORARY ❑ NEW Ifs'REPAIR ❑ OTHER
<br /> 5. ❑ CHEMICAL-TOILETS For July 1,'t June 30, 19
<br /> Type'Constructiori - - - t Disposal Site j _ __ C Ai
<br /> No.of.Units Equipment Storage/Cleaning"Location(s) n�
<br /> 6. ©PACKAGE TREATMENT PLANT For July 1, -June 30, 19 x 4
<br /> Operator'Name ---- -- - ' Where Certified
<br /> .Plant Loca"ti.Qrl 1 ¢ 1
<br /> :Plant Capac ty' r � t No. Units Served y ( s
<br /> 'T. ❑ LAUNDRYiFor July 1, -June 30,19
<br /> SIZE: ❑ Less Than,&60 Sqj'Ft_ S�More Than 1,000;Sq. Ftp, �
<br /> ❑ DRY CLEANING,Chemi'cals Used/Amount/Mo a, --
<br /> "amsowner or licensed agerii'a signature eertlfe sthe failowi-19:"1 certify that iR tite performance of the work tar wbicg this permit is issued,I shall not employ any Person
<br /> in such manner as to became subject to wor k;rati's cotlW.,atioe ia;!s of California,' ►
<br /> Contractor'B'hiring or sub-rnntraZtirsg signature certifies the fo"ow:ng: "t certify that in the performnceof.the work forwhich this permit is issued,i shall }
<br /> employ persons subject to wcrKitlah'S'tampiffiPC YIa"wsfGaltfdrnia;_ 1 - _ .-Sy „-._. . .r--. - . - - S ._
<br /> • i' t r F F j ` - 1A, Y
<br /> hereby certify that l have "preparedNthis`appp a�tion RRRand that the4ork-will be done-in-accordance with-San Joaquin County � r �
<br /> ordinances, state laws, and ules and regulation bf the Sari Joaquin'Local Health District. 1 4 , I
<br /> ' J
<br /> APPLICANT'S SIGNATURE`X �
<br /> 1,4 i. FOR DEPARTMENT USE ONLY ! _
<br /> Fee Is Due: ❑ ANNUALLY ❑ PER-UNIT IJ!PER SITE- ❑ EACH ❑ January 1 &Received By January 31. ❑ July 1 &,Received By July31 ,�
<br /> REMIT
<br /> .BICLING REMITTANCE AMOUNT DUE CHECKEDi
<br /> BASE EXPLANATION •' i
<br /> .DATE ,_-DATE 4 -REMITTED .: _
<br /> ` n _ _ _ 'i` ti,r Y.- AMOUNT
<br /> FEE t-.. �. ,a " r T
<br /> LESS r Y { 3
<br /> PRORATION r # - w 4 - .- A
<br /> LA
<br /> PLUS
<br /> .. PENALTY q s. .t.-- i"" -
<br /> OTHER
<br /> OTHER f _
<br /> E
<br /> Received by Date Receipt No. i I 'Permit Na. i ! I suance Date { Mailed z(Delivered
<br /> APPLICANT RETURN ALL COPIES-TO: '"ENVIRONMENTAL"HEALTH PERMIT/SERVICES""'� ""^ `-1601`i HAZELTON'AVE.,"P.O.Box 2009-`` STOCKTON,CA 95201 -"
<br />
|