|
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.
<br /> APPLICATION
<br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE x
<br /> Application is h reby ma a ko carry on business in the jurisdictional area of the San Joaquin Local Health District
<br /> H Business Name (DBA) , , x,�. '-/Jl� � - Address 5-
<br /> i Owner Address
<br /> L).Firm Partners, Addresses and Telephone Numbers
<br /> aBusiness Telephone No.. - Emergency Telephone No.
<br /> Contractor Licence No.
<br /> L Applicants Name (Print, L44+mak,. Title Date
<br /> Please check Applicable Category(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 /> Desceiption(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 r '' - -
<br /> 3: ❑ PERCOLATION TEST' _j }
<br /> R.S"-or R.C.E. Name �, R.S. or R.C.E. No. I
<br /> y -� ...- .-r.. + r' ,,.i ..._..�.L.-.wt MI�i�F:si''.'''_ - --- Y
<br /> Test Location '"�" " .n ;, Test Date/Time
<br /> 4. ❑ SANITATION PERMIT L
<br /> —� • r
<br /> Job Address/Location ` ' -
<br /> Owner 46 `'Address '
<br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT
<br /> I ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER R C�
<br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 C�
<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 /> L
<br /> Operator Name Where Certified - -
<br /> Plant Location €
<br /> Plant Capacity No. Units Served
<br /> 7. ❑ LAUNDRY For July 1, -June 30, 19
<br /> SIZE: '❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft.
<br />+ ❑ DRY CLEANING, Chemicals Used/AmounVMo.
<br /> r ,
<br /> Home owner arltesnsedollowing:1 certify tholirith ;erformanl;eofthe work for which this permit isissucd.Ishallnot employ any person
<br /> in such manner as to heconlc SLlh,'00 to viorkmaR;:�:+3:+:pcn7 tiof ;?•,,`F:,'.`Califoiri!:t ' .
<br /> ColltractOT's hiring Ot suis-C4;:1tr:,cFira:ti rex1� 'i,ss: ss�rtifsra t.. 3 iervuir. "i certiS,v that ill ti,c j:erforinan,'a of tirevr,,irk fw-xahich this nermil:s issued,I shall ..
<br /> t employ personS 5ub?sC?io v,,ui knlu„;
<br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County
<br /> ordinances, state laws, and rules and regulation of the San Joaquin Local Health District.;-
<br /> APPLICANT'S SIGNATURE X
<br /> 4 a l
<br /> r S 2
<br /> FOR DEPARTMENT USE ONLY
<br /> L Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received-By January 31 ❑'July 1 &Received By July 31
<br /> REMIT
<br /> l BASE EXPLANATION
<br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED
<br />` } DATE DATE REMITTED AMOUNT
<br /> I FEE
<br /> LESS
<br /> PRORATION
<br />' PLUS
<br /> PENALTY _ r
<br /> OTHER
<br /> OTHER
<br /> rP.,)-
<br /> Received.by
<br /> r -
<br /> Date Receipt No., Permit NoIssuance Date Mailed Delivered
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201
<br />
|