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Applications Will Be Processed When Submitted Properlycomplietea. tseo <br /> , <br /> APPLICATION <br /> rte"" (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> /� ENVIRONMENTAL HEALTH PERMIT <br /> c� SastCiL� / LIQUID WASTE <br /> Application is hereby made to carryon business In the jurisdictional area of the San Joaquin Lo al Health Dist r"c ' AL A <br /> 11 11 1.11 Address <br /> wBusiness Name (DBA) } <br /> F Y_ Address <br /> c Owner... b � _ .- <br /> J Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. _ <br /> j a Business Telephone No. H <br /> Contractor Licence No. Da <br /> r g - <br /> Title "'� ."-F---� N F- f� te <br /> a Applicants Name (Print) " <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) CAL. License Renewal No. <br /> Serial No, CAL. License No. a� <br /> Gal.,Weights & Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June•30, 19 <br /> No, of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S.or R.C.E. No. <br /> R.S.or R.C.E. Name d <br /> Test Date/Time <br /> st Location <br /> 4. SANITATION PERMIT 111411111f C-6, <br /> J Address/Location" <br /> Address <br /> Owner . <br /> ❑ PACKAGE PLANT, l e� ._ <br /> MERMANENT <br /> EPTIC TANK ❑ CESSPOOL LEACHING FIELD 0 REPAIRS PIT MOTHER <br /> ❑ TEMPORARY NEW Y rn <br /> 5. C1 CHEMICAL TOILETS For July 1;=June 30, 19:-.--- Y <br /> " Disposal Site x '-�_� <br /> Type Construction. <br /> No. of Units Equipment Storage/Clea_, ning Location(s) <br /> r•. A. -_4 <br /> fi. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> ,, Where Certified <br /> Operator Name` ^' r. " r <br /> I Plant Location_ No.Units Served <br /> Plant Capacity - <br /> - <br /> 7. ❑ LAUNDRY For July 1, -Ju6Q 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,• ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY%,EANING, Chemicals Used/Amount/Mo. <br /> nri+enwharprNtansedhgerlt'esi�+wtr�tscertillwsfMivNow#r :"lcertf Mal lotOwperlarntarteeGfthework1brwhkhfttis#erlriftisissued,Ishalfridlego6y21Yypar3on <br /> in such inatlner as to bectihne subs t to workmarfs campmalian taws oftaiilortwlt." <br /> 4Coniwtor's`•kiting. ar sob-centrooting zhrmf„re eertMes the lnfiww., '1 conify.tlutt in the perforMaime of the work for which this permit is issued,I shall <br /> employ persons subject to workmarfs compensation laws of CafifornigL p <br /> l,hereby cer3'ify,that I have prepared this application and that the work will be done in accordance with San Joaquin C <br /> ordinanuTe`s`_ Ates# 'I'aws, and rule nd regulations of the an Joaquin"Local Health District. - I(8") <br /> l - r 6 yY <br /> AP NT'S SIGNATUREX <br /> " FOR DEPARTMENT USE ONLY - <br /> ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 Jul eceiv REMITyJuty 31 <br /> Fee IS Due: ANNUALLY ❑ <br /> BILLING REMITTANCE $ AMOUNT OUE CHECKED <br /> E? EXPLANATION REMITTED AMOUNT <br /> BASE DATE " DATE <br /> EEE •/ ' <br /> LESS a . <br /> PRORATION <br /> PLUS r <br /> PENALTY i. S <br /> s � <br /> OTHER <br /> OTHER <br /> Rece1601 E.H <br /> ived by <br /> Date Receipt No. Permis No, 1 uance ate Mai ed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> N AVE,,P.O.Box 2009 STOCKTON,CA 95201 <br />