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Applications Will Be Processed When Su6mitted'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
<br /> Appl icatiokt7Cb
<br /> s hereby made to carry on business in the jurisdictional area.of-the San Joaquin Local Health District`Business Name (DBA)� ROOTCR __Address i71 S fi,DeM ef? 1
<br /> z Owner- Address
<br /> J Firm f�hrtners, Addresses and Telephone Numbers
<br /> aBusiness Telephone No. 9 S— a Emergency Telephone No. `
<br /> �
<br /> Contractor Licence No.
<br /> Applicants Name (Print) 2 r"n ..'2 –Title Date tet.
<br /> Please check Applicable Category(1-7) and Fill In the Required lnformation,
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> For July 1, June 30, 19 Disposal Sites
<br /> Description(Make/Yr., Color)
<br /> Serial No. t 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.
<br /> 9:No. of Vehicles Stbred
<br /> No. of Chemical Toilets Stored I
<br /> 3. ❑ PERCOLATION TEST #
<br /> R.S. or R.C.E. Name R.S. or R.C.E. No.
<br /> Test Location Test Date/Time j f
<br /> 4. ❑ SANITATION PERMIT
<br /> Job Address/Location
<br /> Owner Address
<br /> ❑ SEPTIC TANK! ❑ CESSPOOL LEACHING FIELD 13 SEEPAGE PIT ❑ PACKAGE PLANT' T'
<br /> 11 PERMANENT ❑. TEMPORARY 11NEW. r�r ❑ REPAIR ❑ OTHER
<br /> 5. ❑ CHEMICAL.TOILETS For July 1, -June 30, 19 t {�
<br /> Type Construction i Disposal Site
<br /> No. of Units t Equipment Storage/Cleaning Location(s)
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19
<br /> ,Operator Name t I Where Certified _
<br /> Plant Location I
<br /> Plant Capacity i No. Units Served i.
<br /> i 7. ,❑ LAUNDRY For July i, -;June 30, 19 -
<br /> l1 SIZE: ❑ Less Than 1,00D•Sq' Ft., ❑ More Than 1,000 Sq. Ft. h
<br /> I ❑ DRY CLEANING, Chemicals 0sed/Amount/Mo. r
<br />'
<br /> Homeowner orlicensed Agent's,signature certifies thefollowing:"Icertify that inthe perfor€nanceofthsworkforwhichthis permit isissuedjsh�li-nofemployany per son
<br /> in such manner as'to become subJect to workman's compensation laws of f-Ififorwil
<br /> Contractor's,h'An or sub-.COWFacting 9ignpture certifies the fallowing: 1 Cerfify that in the performance of the work for whieh1hi ,permit is issued,I shall f, ;a
<br /> employ persons silbiecf to workman's compensation laws of California"I r< rte'.
<br /> hereby certify that-.1 have prepared this apptic rt an that the work will b��d'one in accordance with San Joaquin County
<br /> ordinances,state laws, an rules and reg f the n Joaquin Local Health Efistrict. r f
<br />? APPLICANT'S SI4NATURE Q t
<br /> F R 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 /> I BILLING REMITTANCE $ r. REMIT
<br /> BASE EXPLANATION AMOUNY.dUE CHECKED
<br /> f I DATE DATE REMITTED , AMOUNT
<br /> FEE � O t_.
<br /> LESS 1
<br />((1` PRORATION -
<br />' PLS __i b ��. ....,�...•.
<br /> PACTY
<br /> OTHER
<br /> OTHERrr-..-,-",.. �-•_....�t..-,.,_- -. ..' �J-r ..,,�-/_.,",. , , �,..,,. �.,..,..- .: - .w, ......«---w-•--"^�. �+ _ ,..�,..e. �e}� .a..- Y .._�.
<br /> Received by Date Receipt No. Permit No, Isstlance Date Mailed Delivered
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601.E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 '
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