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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. M <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> I ENVIRONMENTAL HEALTH-PERMIT <br /> Ilk I LIQUID WASTE _' - <br /> Applica is herepy ma'a to carry o usin ss' the•urisdictional area of the an Joaqu' Local Heal h District , <br /> N Busines ame (DBA) Address& 2 02� <br /> a Owner Address <br /> w <br /> J Firm Partners, Addresses an Tele hon, umbers y s;Au <br /> a Business Telephone No. <br /> Emergency Telephone No..� 1 <br /> Contractor Licence No. <br /> a S'N*- . Title Date_ <br /> L Applicants Nate (Print) ` ` T— ou <br /> > PPaease check Applicable Cate ry(1-7];and Fill in the quired Information <br /> 1. ❑ PUMPER VEHICLe-PERMIT REGIISTRATION (FOR EACH VEHICLE) i <br /> For July 1, June,30'19 -- t_== - Disposal Sites - <br /> UJ <br /> Descriptior (Mfi e/Y,[.,Goi'oi') , <br /> Seriaf ltd, '- CAL. License No. CAL. License Renewal No. +A. <br /> A <br /> Cap`acity"i-•^- �-- ' �� Gai.,Weights & Measures No. <br /> Equipment Parking°Add ess ' <br /> �22�•M❑�I�UfIj1lPEfi'�YAR$�: �� � � <br /> 3 w - <br /> For July-f-;- <br /> , June 30, 19 — _ <br /> FNo. of Vehicles Stored s <br /> No. of Chemical Toilets Stored <br /> k3. ❑ PERCOLATION TEST <br /> 'R.S. or R.C.E.'Name __ R.S.or R.C.E.No. <br /> ,Test Location; ) Test Date/Time <br /> Job Aid ANIITAo ION PERMIT <br /> t Q <br /> ' ,Owner Address <br /> Z1r <br /> ❑ SEPTIC TANK ❑ ESSPOOL �EACHING FIELD I SEEPAGE PIT ❑ PACKAGE PLANT <br /> 5I-VtRMANENT ❑ TEMPORARY ❑ NEW Qa-REPAIR ❑ OTHER <br /> '5. ❑ CHEM#CAL TOILETS For July 1, -June 30, 19 <br /> � W <br /> Type Construction -- —Digosal'Site <br /> .No. of Units t y +, Equipment Storage/Cleaning Lb"cation(s) <br /> �6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19•` <br /> 3 �'-," -t `tt� r, Where Certified <br /> Operator Name - � w - - - , <br /> 'Plant Location t <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19' _ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ Mdre.Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/l.Mo <br /> tome ow4 r or licensed agent's signatareaertiriesth+ following:"l certify that in the performonce of the work for which this permit is issued,I shall not erhpioy any person <br /> ] in such manner as to become subject to warYman`9 compeR�gtioa laws ofCahfornia,' <br /> Gantractor's hiring or sub-contracting sigria'ture.ee,4*s the failowing, :1 certify that irr the performance of the work for which this permit is issued,I shall <br /> empley persons subject to workmans compensatign laws of caHfomia." <br /> + 7J I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> l ordinances, state laws, and rules arid regul ions of tA San Joaquin Local Health District. <br /> l <br /> 'APPLICANT'S SIGNATURE X 4 <br /> FOR-DEPARTMENT USE ONLY L <br /> r (sem <br /> IS Due: ❑-ANNUALLY ❑ PER UNIT ❑ PER SITE 11 EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> j BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> f „ DATE DATE REMITTED AMOUNT <br /> t ; FEE i <br /> x <br /> C LESS x <br /> I PRORATION <br /> PLUS t f <br /> PENALTY. <br /> OTHER a <br /> OTHER <br /> 7T Q <br /> <. Received by Date Receipt No Permit NoTs trance ate Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEgM1T/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br /> .. <br />