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Applications Will Be Processed When Submitted Properly Completed BeSure Io ZoIgn Ie,V <br /> APPLICATION ' <br /> a (For Non-Transferable, Rdvocabie;'and Suspendabie) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> 3 LIQUID WASTE <br /> Applica ' is hereby m de to cprry.on bus ess'n the jurisdictional area of the n�loa n Local Health District <br /> Address �8 <br /> en Busines ame (DBA) - <br /> z Owne _ .Address .. :, . <br /> v 4 <br /> dc <br /> J Firm Partners, Addresses and Tele hon umbers Emergency Telephone No. . <br /> a a Business Telephone No. <br /> 2 Z <br /> Contractor Licence No. ' <br /> a ,g, y Title : Date <br /> Applicants'Name (,Print} `' <br /> 1-7 and Fill in the uired information t i, , '.^, .4r�.' ` `_ .. 1 <br /> PJpa'se-check Appleable�Gat ry ( ) <br /> ❑PUMPER_VEHIC&PERMIT REGISTRATION (FOA EACH VEHICLE) <br /> t' Disposal Sites . <br /> For Ju)y 1 4 June30, 19. - - p <br /> Description(Make/Yr`,C'olo4 CAL. License No. CAL. License Renewal Na. <br /> 4 <br /> e. y;� <br /> i. Serial �°"':.. ��3--'." <br /> Capacity Gal., <br /> Gal.,Weights & Measures No. <br /> Equiprh@nt;Parking'Addr`ess } <br /> Z. ❑`PUMPEA,;Y- ARD <br /> For°July 1; !I ` P'June"30, 19 $ <br /> jNo of,Vehicles Stiored - <br /> �Vo. of Chemical Toilets Stored i <br /> 3. ❑ PERCOLATION TEST--*•ti••— -----^^-- '--- <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name " <br /> Test Date/t,ime <br /> Test Loc tion <br /> 4. SANITATION PERMIT ' *S til i�r� <br /> 1 <br /> 9`f�GJ <br /> Job Addre s/Locati°n - ---•-` ` __�....1 <br /> Own - <br /> �SE"PTIC TANK!' 13 CESSPOOL _ ❑ LEACHING FIELD ' ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> _ <br /> LAS PERMANENT <br /> TEMPORARY ❑ NEW �F{EPAIR <br /> } +✓ s. <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 1 l v <br /> Type Construction'. Disposal Site <br /> Equipment Storage/Cleaning Location(s) ; <br /> No. of Units ^' G <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where.Certified <br /> Operator Name <br /> Plant Location i ) <br /> Plant Capacity ( No. Units Served _ <br /> E <br /> 7. 13LAUNDRY For July 1, -June 30, 19 — <br /> SIZE: ElLess Than 1,000 Sq. Ft., ElMore Than 1,000 Sq. Ft. r <br /> ❑ DRY ,n Usgd/AmounVMo. <br /> "}cerlityythat inth8perfvrm�rtCeotthew rkfvrwhiCttl►ispermtisis5ued,tshalinvtempfoyanypersc� dee: . entsenalurecPrtifeshfaowing: <br /> irl sueh manner as to becaiw,:sub;ect'o rlorkman's eWnnWsat:on laws Of califomia.' 0 <br /> tk Contractafs hiring or sub-cm-armiing signetvre cartituas sho fo1'owiRg: "k certify that Irl i�0 p�rTDwmanceof the v+prk for vit�i�Ghosis hermit is issued,I shall <br /> emptay p>;I'sons subject tv r+arkmen's cutnpensntion la__v,s_utCalifuraia.'`, ........�..•�------� - <br /> I hereby certify that I have prepared this application and that the work will be done ip accordance with San Joaquin Count <br /> ordinances, state laws, a d rules and ref ulations of the San Joaquin ocal Health Distract . +, <br /> APPLICANT'S SIGNATURE <br /> 6 FOR DEPARTMENT USeONLYI Byi ' <br /> . .w, <br /> Fee Is Due: D ANNUALLY ElPER UNIT ❑ PER SITE ❑ EACH. ❑ January i &Received By January 31 ❑ July 1 &Receiv REMI July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> . _ DATE - DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER .-- ---- _. - -•— - `_...:'.'... - <br /> OTHER '1 r <br /> Date Receipt No, Permit No, I uance ate , Mailed Delivered <br /> Received by - 1601 E.HAZELTON AVE.,P.O.Box 2008 STOCKTON.CA95201 <br /> .APPLICANT—RETURN ALL COPIES TO: ��ENVIRONMENTAL HEALTH PERMITlSERYICES <br />