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( Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> a <br /> (For Non-Transferable,Revocable,and Suspendable) <br /> ter. SEPTAGE <br /> - - -�''YENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> I Application is herel1y mad to car on busines in ejurisdictional area of the n oaqu1 Loca!Health District <br /> FBusines me (DBA) Address <br /> i Owner Address ,� �"' <br /> a v <br /> c J.Firm Partners, Addresses and T lephone umbers - c/} <br /> ' IL Business Telephone No. � Emergency Telephone No. <br /> i <br /> Contractor Licence Na. ZZ- 1 <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Cat ary(1-7)and Fill in he Required Information <br /> •1: ❑.;PUMP,.ER VEHICLE PERMIT-REGISTRATION (FOR EACH VEHICLE) <br /> For.July 1, June 30,-19 Disposal Sites <br /> Description.(Make/Yr., Color-..)_s <br /> Serial No. CAL. License No, CAL. License Renewal No. <br /> w <br /> Capacity ' k l -Gal., Weights & Measures No. <br /> Equipment Parking Abdress <br /> 2. ❑ PUMPER YARD •� <br /> For July 1' �y June 30, 19 <br /> No. of Vehicles Stored f , <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> s R.S. or R.C.E. Name, " R.S. or R.C.E. No. <br /> Testi LoPation Test Date/Time <br /> 4. f1 SANITATION PERMIT <br /> CZ 1 Job Addr s Location 'd` _ 6 <br /> k Owner Address <br /> ' ED SEPTIC TANK ❑ CESSPOOL ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT !! <br /> E-PERMANENT ❑ TEMPORARY _N_EW �EPAIR OTHER SI.1/Y�� 20 -2 7 ' <br /> 5. 11CHEMICAL TOILETS For July 1,-June 30. 19 ' <br /> �+ Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> f 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30,19 <br /> Operator Name _.Where Certified <br /> -yam �..e-..-...yy�t - . a- a. � •-• -- -eu-..�, - T Y <br /> Plant Location <br /> Plant Capacity No. Units Served " <br /> i <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19. <br /> k` SIZE: © Less Than-l-,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> I ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Hoenet►rerrerorlioanasd @fewCs certifythat inthe performheworiil'cr <br /> ance of twhith thisaermit is issued,I shall not employ any pereon <br /> kI such manner as to.tteteme subject to workman s compensation laws of California," <br /> � } <br /> COMMWtdr's hiring-or subcontracting sierwtum certiflee Nie fanswAni `I certify that in the performance of the wank for which this permit isissued t ttheN - <br /> employ Weans su to won(i an's compensation laws at California' <br /> I hereby certify that I-have prepared this application and that the work will be done in accordance with San Joaquin County 1�+ <br /> ordinances„state laws, nd rules and re ulati s of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X r w <br /> = FOR DEPARTMENT USE ONLY r <br /> Fee Is Due: ❑ ANNUALLY, ❑ PER UNIT ❑ PER.SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> E BILLING REMITTANCE $ <br /> BASE EXPLANATION+ .DATE DATE REMITTED AMOUNT DUE CHECKED <br /> .. t AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i OTHER Y <br /> I Received by - Date r Receipt No. Permit No. issuaned Date Mailed Delivered ,f <br /> d APPLICANT- RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16131 E.HAZELTON AVE.,P.O.Box,2009 STOCKTON,CA 95201 ,f/+ <br />