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Applications Will Be Processed When Submitted Properly Completed. Be SureTo sign <br /> APPLICATION <br />,t (For Non-Transferable, Revocable,and Suspendable) SEPTAGE r <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applic n is hereby made to rry on busines int a jur' dictional area of the Sa Joa in Local Health Dis ict <br /> r w Address <br /> lhBusiness me (D <br /> aOwner —� Address <br /> j Firm Partners, Addresses a Telephone Num ers <br /> a Business Tel <br /> No. / -Emergency Telephone No. A , <br /> Contractor Licence No. 7- <br /> Title, 1- -Date (1 } <br /> Applicants Name (Print} > .. T <br /> please check�Applicab a Cate ory (1-7}and Fill in�theuired Inlormation r <br /> 1/ ❑-PUMPER..VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For`Juky 1,'° k'-- -June 30,,19• Disposal Sites. <br /> Descriptiioii(Make/Yr.,'(fofor) CAL. License Renewal No. <br /> ". <br /> Serial No. CAL. License No. <br /> �-Gal.;-Weights&-Measures-No: <br /> - - - i <br />•----Capacity----� ......--�..-..�" - � <br /> Equipment-Parking,Addres'S } <br /> 2. ❑ PUMPER YARD, <br /> For July <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST (1 i <br /> R.S. or R.C.E. No. 4 <br /> R.S. or R.C.E. Name ` <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT r- -- "' """'"" , <br /> Job Address Location <br /> i Address <br /> Owner , <br /> 11w�a� BEACHING SEEPAGE PIT ❑ PACKAGE PLANT! <br /> R, ❑ CESSPOOL FIELD <br /> SEPTIC TANK <br /> MRMANENT ❑ TEMPORARY CHEW 13 REPAIR <br /> �E <br /> I 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction r^-Disposal Site- I <br /> r ! .. - <br /> No�r of.Units Equwlpme�t Storage/Cleaning Loc aptien(s) <br /> 6. ❑ KAGE TIAIATMENT.PLANT Far July 1,;Juner30; 19 <br /> PAC <br /> Where Certified <br /> r Operator Name - - _. �,»;, _- _,.... ��.. - - _,r M 4�. <br /> Plant Location <br /> r No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1;-June•30,y1,9..—�.r •�--- �-` <br /> Com\ <br /> SIZE: 11 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. _ . ... - <br /> Nome ownerorlicensed agent'ssignature L6rtifiesthefollowing:"lcertify trot In the perlormanceoftheUrorkforwhichifiispermit+ issued.fshaltnotemployanyperson <br /> in such manner as to become subject to warkmar.'s campansation laws of California:' <br /> lab-contracting signatum rorti5et 11ty folrowing: "i co,Eity that in the perfermallce f the work far whirr+this permit is issued,1 shall <br /> Contractor's hiring or s <br /> employ persons subject to o+olkniar s cnrnpellsaticli lava cf Ca!it�'rnica.' S <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance wit 0 San Joaquin County <br /> ordinances, state laws, a rules and re do of the San Joaquin Local Health District. i <br /> 1[ APPLICANT'S SIGNATURE X <br /> k f�� <br /> 1 <br /> i FOR DEPARTMENT USE ONLY <br /> t -•� d By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By uary 31 f ❑july 1 &ReceiveREMITuly 31 <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE RE T ED AMOUNT <br /> I _ - <br /> FEE <br /> 4 LESS ` • '� <br /> PRORATION + r <br /> ` PLUS { <br /> I PENALTY <br /> ! OTHER <br /> t , <br /> OTHER <br /> Isuan <br /> Date Receipt No. Permit No. Date Mailed Delivered <br /> Received by - 16D1 E.HAZELTON AVE.,P.O.Box 2009 STOC%TON,CA 95201'— <br /> APPLICANT—RETURN <br /> 5261APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />