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Applications Will Be Processed When Submitted Properly Completed. Be SureTosign tnes.ppucattvil. <br /> ' APPLICATiON <br /> (For Non-Transferable,Revocable, and Suspendable) / SEPTAGE <br /> F ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District, <br /> Business Name (DBA) Address <br /> z Owner Address , <br /> a - <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. _ Emergency Telephone No. <br /> Contractor Licence No, I <br /> L Applicants Name(Print) j54 Al Title lAl`2 — Date 1 <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Q <br /> For July 1, June 30, 19 - = :Disposal Sites ' <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. j <br /> Capacity "Gal:,,Weights & Measures No. 1 <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 <br /> ► <br /> .S. or R.C.E. Name R.S.Ror R.C.E. No. <br /> _ - <br /> Test Location `# Test Date/Time <br /> 4. P4 SANITATION PERMIT <br /> Job Address/Location 2S _5�7- <br /> TGA h <br /> Owner 20l5 F-p y a g Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD, 1:1SEEPAGE PIT"13 PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 t' <br /> Type Construction Disposal Site Y <br /> No. of Units Equipment Storage/Cleaning'Gocation(s) - <br /> t s <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 4 ; <br /> Operator Name I Where Certified <br /> A <br /> Plant Location I F <br /> Plant Capacity T No. Units Served. <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 I <br /> SIZE: 11 Less Than 1,000 Sq. Ft., <br /> ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. ` :- ' = j <br /> Horne owner orlicesnsodagent'ssignatt&ecertifiasthc'fc:Ie��in :'9rerti;ythatfr:She:perfcrmancpoftheworkfors�:hichihispermitisissue.d,Ishaflnotemployanyptrsan <br /> in suc?t manner as to become subject to ttia:t�ma,.'s campet}sa:ion l:sr_of t;F:iii;r[i. <br /> Contraatnr's h;riseg or..ytsb-cone&ming �icnawre c;as'i4ies the ioliowirlu:J i certify fhat inthe pertornia ce of the work for which this permit is issued,I shall. <br /> employ persons subject to workman's coll}pensatler.laws aS Caiifol;;ia." <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Join County <br /> ordinances, state laws, an rul and regulati sof th San Joaquin Local Health District. <br /> C <br /> APPLICANT'S SIGNATURE X <br /> s <br /> FOR DEPARTMENT USE ONLYBy- <br /> Fee Is Due: E3 ANNUALLY ANNUALLY ❑ PUNIT ❑ PER SITE ❑ EACH _ ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveR�EMITuly 31 <br /> BASE EXPLANATION BILLING M REMITTANCE $ AMOUNT DUE CHECKED - <br /> �'k- DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS t <br /> PRORATION <br /> PLUS <br /> PENALTY .I <br /> OTHER t <br /> OTHER <br /> D to I Receipt No. Permit No ' Issuance Date Mailed Delivered <br /> Received byAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.}IA2ELTON AVE..AYEP.O.Box 2004 STOGKTON,CA 95201 <br /> I <br />