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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. T
<br /> APPLICATION
<br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGF
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE -
<br /> y` Application is h eby made to carry on business in the jurisdictional area of the San Joaquin Local Health District
<br /> ,�Business Name (DBA) Address_ Z r>k , :57 Q 20
<br /> z Owner
<br /> dc Address
<br /> Firm Partners, Addresses and Telephone NumbersCL
<br /> a Business Telephone No. Q7 Emergency Telephone No,
<br /> Contractor Licence No. Z `' -
<br /> L Applicants Name (Print)
<br /> • _ Title, Date
<br /> Please check Applicable PP Category g ry(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)
<br /> Serial No. CAL. License No~ "- dAL. License-Renewal No.
<br /> Capacity Gal;"Weights &M asures No, n
<br /> Equipment Parking.Pddress"
<br /> es
<br /> 2. ❑ PUMPER YARD _
<br /> r F
<br /> For Juljrl,�� 4June 30,'19 t ) �� l 3 Tj�`
<br /> '"No. of Vehicles Stored
<br /> No. of Chemical,Toiiets 5torIedn
<br /> &� +-• —
<br /> 3. ❑ PERCOLATION TEST
<br /> R.S. or R.C.E. Name R.S. or R.C.E. No.
<br /> 7,e Location...
<br /> Test Date/Time'
<br /> 4.`SANITATION PERMIT
<br /> . Job Address/Location
<br /> Owner Address" ,?, t
<br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD WSEEPAGE PIT ❑ PACKAGE PLANT. �r
<br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑`OTHER •!` 4f
<br /> 5. 13 CHEMICAL TOILETS For July 1, -June 30, 19 ,,. ,
<br /> Type Construction ; ' #
<br /> Disposal.5ite J/
<br /> No. of Units Equipment Storage/Cleaning Location (s)
<br /> S. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19
<br /> Operator Name . Where"Certified' ;
<br /> Plant Location
<br /> Plant Capacity No. Units Servedd�`
<br /> 7. ❑ LAUNDRY For July.1, -June 30, 19
<br /> SIZE: ❑ Less Than 1,000 Sq. Ft., © More Than 1,000 Sq. Ft. ' r
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo"" �..• .• -="_"�+, i,�;; �.- �;;
<br /> NomoOwner ortieensedagent'ssignaturecerttfiesthefa'towing;"fCertit fhr,tithe r { t
<br /> y performance cf the:rcrk fo:ivhi,cll tt s permit is issued,!shall n�err,Iuy nyr p=
<br /> in such manner as to huco] su3ject n to rtc certifies
<br /> nmpansatien ia,vs c'California.'
<br /> Contractor's F.irin or auls-
<br /> S1 Gonl:actin si�naFc:ra carYifi is tf:e !P1 c2wino: "t C?fFify,hof iR t!"le GCr10rn171 Cv 0 t l:�[ 1�r 4^.I?jCh Ihi9 llermit,l iS "' I '";II
<br /> employ persons scbject to vlorkman's compensation lav"Is of Catifelma.''
<br /> I hereby certify that I have prepared this-appl!cation and that the work will .be done in accoedance with San Joaquin County
<br /> ordinances, state laws, and r I a regulat ons he SanrJoa h Local Heigh Di trio- ( D� Q ,
<br /> APPLICANT'S SIGNATURE X
<br /> - FOR DEPARTMENT USE.
<br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT. ❑ PER SITE
<br /> ❑ EACH ❑ January 1 &R ed By January 31 ❑Ju1yi?'-iReceived By July 31 !
<br /> iBiIaING T R� I _- - - REMIT
<br /> BASE EXPLANATION TTANCE M" -AMOUNT DUE.-. CHECKED
<br /> pD&EDATE.,REMITTED .
<br /> � - AMOUNT
<br /> n=.
<br /> FEE ,
<br /> LESS
<br /> PRORATION
<br /> PLUS
<br /> PENALTY -
<br /> OTHER 1 .
<br /> 01HER
<br /> Receive6 b - Receiptr
<br /> y Date
<br /> No. R 'Permit No. Issuance Date Mailed' Delivered ..,
<br /> ApPLlCANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201
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