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Applications Will Be Processed When Submitted teProperly ONpfete . e u <br /> re <br /> (For Nan-Transferable;Revocable, and Suspendable) SEPTAGE �A <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE t <br /> . s��•�s-?�' Applica n is hereby made carry on business in the jurisdictional area of tl}�San JO gain Loc 1 Health 1J• trlct , <br /> 2pAIS,�,(JG Addres <br /> mBusiness Name (DBA) Address . <br /> z Owner A w <br /> a - <br /> Firm Partners, Addresses and Telephone Numbers --Emergency Telephone No. <br /> aBusiness Telephone No. - 1` <br /> j Contractor Licence No. - - Date_.7- <br /> Title � <br /> Title <br /> L Applicants Name (Print) w Y' <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 ti <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License 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 Y <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> 4. SANITATION PERMIT 10 11 I_611h <br /> 4 Job Address/ ovation Address <br /> Owner- 13PACKAGE PLANT <br /> 11 SEPTIC TANK 13 CESSPOOL �EACHING FIELD ❑ SEEPAGE PIT OTHER <br /> PERMANENT ❑ TEMPORARY 1:1NEW rtTREPAIR <br /> 5. 13 CHEMICAL TOILETS For July 1, =June 30, 19 <br /> Type Construction <br /> Disposal Site <br /> ~' <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> I ' <br /> g. © PACKAGE TREATMENT PLANT For July 5, 1June 30, 19 Where Certified <br /> Operator Name <br /> *r'Plant Location t <br /> No. Units Served <br /> Plant Capacity ' <br /> 7. ❑ LAUNDRY For'J'uly 1,*June 30, 19 ^ <br /> SIZE: Less Than 1,000 Sq. Ft.,. ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/AmotinUMo. = shall <br /> Noma owner or licensedageM'sQgnatutkma�ltstcompensation6%vsa'Calii00IV,_that In'theperforr;lanceofthewarkiOcetoltri�wlopklarwhickthislpermiiisissuelYishallny r�nn <br /> in such manner as to become subject to we -#certify that in the perfo(M <br /> Contractor's hiring ror sub-conMtetin9 >ns <br /> nature certifies the follovnng: Y f <br /> employ persons Subject to SYorkmail's compensation is trs of California." <br /> I hereby certify that I have pr pared this application and that the k will be done in accordance with San Joaquin County <br /> ordinances, state laws, and regulatio of the S Jo ui Lo al Health District. <br /> i APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USEONLY3 <br /> ❑ ❑ ❑ EA SITE ❑ EACH ❑ January 1 &Received By January 31 ElJuty 1 &ReceivedEIV31 <br /> Fee Is Due: ANNUALLY PER UNIT P <br /> ` BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> 6' o O <br /> FEE- <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY'^- <br /> OTHER <br /> OTHER <br /> DaSe Receipt No Permit No. I suanc Date Mailed Delivered <br /> +, <br /> Received'hy ,: 7601 E.HAZELT VE.,P.O.Box 2009 STOCKTON,CA 95.- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTHAMIT/SERVICES <br />