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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 /> "
<br /> ENVIRONMENTAL HEALTH PERMIT l
<br /> LIQUID WASTE /
<br /> Application is hereby made to carry on b mj
<br /> ess in the urisdictional area of the San Joaquin Local Health District �,
<br /> Lr Business Name (DBA), RA�e a C ,�� Ve` AddressP1k i - v-�-Y~7Z_ —
<br /> z Owner Address
<br /> 9 Firm Partners, Addresses and Telephone Numbers
<br /> 116
<br /> Business Telephone No.. K Emergency Telephone No.
<br /> _J Contractor Licence No. `
<br /> Applicants Name {Print) 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 /> Description(Make/Yr., Color)
<br /> Serial-No- CAL. License No. - -- + -- -�- • " CAL. License Renewal No.Y — -- -
<br /> Capacity _ Gal., Weights &Measures No.
<br /> >=qui�r�1`ent F'-a�r�ing.'Address `" �
<br /> 2. ❑ PUMPER YARD ,�'"y"""•_.-_.z� . . ,__..�. -r-.,,w...•,...�.- n,._...,... �.--...,-.._--_,..,.,,.�„�,...,.,.�...,,;,..«..,.:._.,__.�r-�""....."a."".." '
<br /> Far July 1. June 30, 19 dot
<br /> No- oiA isles}stored tf -
<br /> - r Al
<br /> No. of Chemical Toilets Stored -
<br /> 3.10 PERCOLATION TEST
<br /> R.S. or R.C.E. Name R.S.or R.C.E. No.
<br /> Tc
<br /> L cationf Test Date/Time '
<br /> 4,; SANITATION PERMIT:"
<br /> Job Address/Location r �
<br /> LAddress I 3
<br /> Owner
<br /> ❑ SEPTIC TANK [TCESSPOOL i KLEACHING FIELDSEEPAGE PIT ❑ PACKAGE PLANT
<br /> PERMANENT C1 TEMPORARY 13 NEW /REPAIR ❑ OTHER
<br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19
<br /> Type Construction I Disposal Site
<br /> No. of Unitsf t Equipment Storage/Cleaning Location(s) -�r
<br /> 6.= ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19
<br /> Operator Name W1ere Certified ( r
<br /> Plant L I ation4 .
<br /> i tr.- • } ) i
<br /> Plant Capacity No. Units Served I ;
<br /> 7.i ❑ LAUNDRY For July 1, -4june 30, 19
<br /> SIZE: ❑ Less Than 1,000 Sq! Ft., ❑ More Than 1,000 Sq. Ft. ? }
<br /> ❑ DRY CLEANING, Chemicals hySpe /Amount/Mo.
<br /> Home owner oriicensedagor�sas`:�gnaturecertifiestt,eintEnv„nia:"Irerlifuthat in the performance ofthe w'orkforrahichthis permitisissued,IShall netemptoyany person ;
<br /> in such manner as to become sytijO to workman's cnmpr:n!aMioo
<br /> I Contractor's hiring or sub-contraczinc signatur cr ?: s iai;ui:,.,. "I certify that in the performance of[lievaork.or whiGi this permit is issued,t shall I
<br /> ( employ persons subject to war4-ih-1 s conlpensatien-lavas-of GlMornia-" ) ;
<br /> I hereby Certify that illhav p epared this application and that he work will be done in accordance with San Joaquin Cduinty
<br /> ordinances, state laws,;: d r and regulatio f the 5aquin Loc ealth District. r 1
<br /> APPLICANT'S SIGNATURE — r -
<br /> " 7 "
<br /> /
<br /> r{ c FJuly
<br /> FOR DEPARTMENT,USE QNLY'� �I ;
<br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑EACH 1:1Januaty 1 8 RSceived8y 4;nuSry 31 ❑ July 1 &Received B
<br /> iBICLI�IG' i ITTANGE �t $ <s REMIT .
<br /> BASE EXPLANATION rtet .R �..r '� AMOUNT DUE CHECKED
<br /> DATE DATE REMITTED - AMOUNT
<br /> > r
<br /> FEE dr, O t
<br /> LESS
<br /> PRORATION
<br /> I
<br /> y PLUS e -
<br /> jf PENALTY
<br /> OTHER -
<br /> i
<br /> OTHER` .,.. +»« .w_ :_ s .�
<br /> i G 4
<br /> Received by Date 'Receipt No. Permit No. Iss ante Dae - 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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