|
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.
<br /> APPLICATION I
<br /> 4` (For Non-Transferable; Revocable','and Suspendable) SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID!WASTE
<br /> Application is herebVrladdtlq carry usi a in the jurisdictional area of the Joaqu. L - I He h District
<br /> rn Business e ( A) Address
<br /> Ir�� r
<br /> aOwner_ , �5*Ag6 Address
<br /> Firm Partners, Addresses a� lep
<br /> hone Numbers
<br /> (G r
<br /> EL Business Telephone No.. Emergency Telephone No. � + 4
<br /> Contractor Licence No.
<br /> L
<br /> �[� c....Applicants Name (Prink) � - -, ., Title . , Date 6
<br /> Please check Applicable Categary.(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 t
<br /> Description(Make/Yr.,Color) ;
<br /> Serial No. CAL. License No. CAL. License Renewal No.
<br /> Capacity Gal.,Weights & Measures No. =
<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 ., Z ►, �.. a > __ ��; , ',: , --
<br /> .R.S. or R.C.E. Name t _ Y 4 R.S. or R.C.E,-No.
<br /> Test Location Test Date/Time '
<br /> 4. CTI
<br /> SANITATION PERMIT -
<br /> Job Ad ss/Location
<br /> j,w,��ner Address
<br /> SEP C TANK ❑ CESSPOOL 011 EACHING FIELD �SEEPAGE PIT El PACKAGE PLANT
<br /> 5 PERMANENT ❑ TEMPORARY ❑ NEW M-REPAIR ❑ OTHER
<br /> 5. .11 CHEMICAL TOILETS For July 1, -June 30, 19 ,`J.
<br /> Type Construction Disposal Site
<br /> No. of Units Equipment Storage/Cleaning Location(s) {^
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June.30,19
<br /> Operator Name Where Certified W
<br /> Plant Location ` r
<br /> Plant Capacity �� No. Units Served
<br /> 7. ❑"LAUNDRY For July 1, -June 30, 19 rf J I
<br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ !More Than 1,000 Sq. Ft.
<br /> :J
<br /> ❑ DRY CLEANING, Chemicals Used/Amoun•
<br /> t/Mo.
<br /> Home owner or licensed agent's signature eertrfeea shatOtto,ving;"I certify that In the performance of the work for which this parm it is issued,I sh'II n of em'loy any pars0r
<br /> it such manner as to beCOr"Subject to workman's compensation laws of Catilornla.'
<br /> Conttactdr's htrittg or aub cont actf,rg sgnature csrtiftea a tottovAng: "I certify that in the performance o`the work for wwit ibis permil is iss�led,i.shaft �x
<br /> employ persons subject to wwttlnan'5 cElrRpensation laws of California" 'V i
<br /> t
<br /> hereby certify that I have pr6pared this licatio and that the work will be done in accordance with San Joaquin County
<br /> ordinances, state laws, a ,an gu o he San Joaquin Local Health District. ) %
<br /> APPLICANT'S SIGNATURE X
<br /> FOR DEPARTMENT USE ONLY
<br /> '-
<br /> Fee IS Due: ❑ ANNUALLY PER UNIT PER SITE .❑ EACH.j ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31
<br /> BILLI.41?NG' ^ REMITTANCE $ i REMIT
<br /> BASE EXPLANATION i } AMOUNT DUE CHECKED j
<br /> f DATE ., DATE v REMITTED t �t IAMOUNT 1
<br /> FEE
<br /> LESS
<br /> PRORATION '}.... .,:,,�-,�--�,. .. 4
<br /> PLUS " -
<br /> PENALTY
<br /> OTHER
<br /> ., .^��.-.... ..,--^.-ik...�.-:.�� ... .- ...�-:rte-.m.,.r —e-»�rs�.s+r-.� +c,.".•.'-,.—,,....— -
<br /> OTHER
<br /> Received by Date Receipt No. Permit No. ssuanc ate Mailed Delivered
<br /> APPLICANT;-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201
<br />
|