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s Applications Will Be Processed When Submitted Properly Completed. BeSure Io aI n 1r,�nNr•4� <br /> APPLICATION ' ` . <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT 'f <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health Districk, <br /> I <br /> Address <br /> Business Name (DBA) -• `� %yJ / G�_ <br /> z Owner A4 -Address <br /> •Address <br /> Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> CL Business Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) /M <br /> l� r Title G-� L� Date .., <br /> Please check Applicable Category (1-7)and Fill in the Requires!Information , <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) t�� <br /> For July 1, June 30, 19 Disposat Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CRL. License No. I <br /> Capacity Gal.,Weights & Measures No. { .: <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD t <br /> y For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemidal Toilets Stored A <br /> 3. ❑ PERCOLATION TEST `"" f <br /> R.S. or+R.C.E.°No., I� <br /> R.S. or R.C.E. Name <br /> Tes Location Test bate/Time <br /> 4. XiANITATION PERMI. r <br /> Job Address/Location <br /> O.wn Address <br /> L1 SC�E-PTIC TANK t 11 CESSPOOL — —1 <br /> LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> AN ENT ❑ TEMPORARY "EW <br /> ❑ REPAIR El OTHER <br /> 5. 1:1 CHEMICAL TOILETS For July 1,=June 30, 19 i <br /> Type Construction Disposal Site <br /> No.of Units Equipment Storage/Cleaning Location(s) - <br /> F ' <br /> C, 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Where Certified 44- <br /> Operator Name I <br /> f Plant Location <br /> Units Served <br /> Plant Capacity "+ - <br /> 7. ❑ LAUNDRY For July 1, -June-30, 19 <br /> ti. ' y"^'"❑ 'Mord Tian 1,000 Sq. Ft. 0L c <br /> SIZE: ❑ Less Than 1-OOOWSq.`Ft., <br /> 11 DRY DRY CLEANING, Chemicals Used/Amount/Mo. �. i„a <br /> Homeownararticanse'dagcnt'§ iSnafurec� fis+ the#ottowing:"lcerti{ythq rt.€leper' rmanceot3i�eworkTorlvhic#tthispermit isisslsed,lshalinotemployanyper,a <br /> in such manner as to be�ame subject to workman's cnrnpensatioaws of C,ifornii4 116Contractbr's hiring or sub-conitacting signature rert!fm,'t-he wire:ing: "I certif",that iinthe pi',I 1 artce of the work for which this permit is issued.I shall <br /> .employ persons subject to workman's compens,6,n la:I:s of C litr:rnly. , - <br /> fy that I have prepared'this application and <br /> hereby certithat the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulat nn.s of a Saoaquin Local Health District <br /> l APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t &Received By January 31 ❑ July 1 &ReceiveRdE l yJuly 31 <br /> BASE EXPLANATION DATE <br /> REMITTANCE $ AMOUNT DUE CHECKED <br /> - DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> i <br /> PLUS ;.. . <br /> t PENALTY _ <br /> OTHER <br /> OTHER <br /> I b 'b 7,5 <br /> r)) <br /> ` Per o. Ise nce to Mailed Delivered <br /> eceived Y Oa Receipt No. <br /> 1601 E.HAZELTON AVE-,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />