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Applications Will Be Processed When Submitted ProperlyCompleted. BeSureToSign TheAppimatlon. <br /> APPLICATION <br /> 1 <br /> (For Non-Transferable;Re-vocable,'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is by Made to car us' in jurisdictional area of the S Joaquin Lo �,FI ieaith strict � <br /> rn Business Na DBA) Address- *";`� 1 f <br /> -141 <br /> a Owner .. Addressas 40, <br /> • <br /> Firm Partners, Addresses and Telephone Numbers <br /> CIL Business^Telephone No.. :.> `- Emergency Telephone No <br /> Contractor Licence No. <br /> a � Title y2"�/. Date <br /> Applicants Name (Print) �, { <br /> Please check Applicable Category (1_-7) and Fill in the Required Information l m irk; <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1;=. 'June 30,19--_ '_w - ---�:- Disposal Sites <br /> Description(Niake/Yr.,Golor) r, <br /> Serial No: <br /> � CAL. License No. CAL- License Renewal No. <br /> Capacity Gal.,Weights&Measures No. <br /> Equipment Parking Address ! I. y <br /> 2. ❑ PUMPER YARD ) <br /> For July 1,— June 30, 19 _ <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST ' <br /> R.S. or R.C.E. Name ` R!S.or R.C:E. No. J <br /> Test Location Test Date/Time Q) <br /> 4. SANITATION PERMIT <br /> Q 5 ' <br /> Job Address/Location <br /> Owner `� Address—,- <br /> ❑ SEPTIC TANK 11 CESSPOOL ' r�++�J_EACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT F �i <br /> ❑ PERMANENT ❑ TEMPORARY '-1-13 NEW I `ti XRREPAIR OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site 4. - <br /> No. of Units Equipment Storage/Cleaning Location(s)a <br /> fi. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> __ . <br /> Plant Location f i <br /> Plant Capacity I No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq_. Ft., El More Than 1,000 Sq. Ft, r. <br /> 13 DRY CLEANING, Chemicals Used/Amount/Mo. <br /> #fpntaowm►►arllaansosin8e++t'►sl maturaaortHiesthe[oliou,�ing:"acertily!ha!ilthepertormanceoffheworkf❑rwh3chthis Erinilisisstied,lShallnotemplayastyp <br /> person <br /> In such manner as to become sublacfto Workman's c0mpensA110:111Ws el Ca ltarnia." <br /> Cantreotar's hiring or euG•e ant►deting oignotura certifies the-foflcvning;.,"I certify.fiat'M the perfornlancc of the work for which this permit is issued,i shall <br /> ompl9y persons 6ub)Qcl to workman s cornpe^sation laws of California. <br /> I hereby certify that I have pr pared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an ul s and ftulations the San Joaquin L al Health Distric <br /> _ , <br /> APPLICANT'S SIGNATURE X _ <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE _ ❑ EACH ❑ January 1 &Received By January 31 ElJuly 1 &Received By July 31 <br /> -^ REMIT ' <br /> BASE: 'EXPLANATION BILLING REMITTANCE .$ AMOUNT DUE CHECKED ' <br /> _ - DATE --`IDATE -REMITTED AMOUNT , <br /> FEE ; <br /> LESS <br /> -PRORATION <br /> PLUS <br /> PENALTY <br /> 1 OTHER rc. .k .,� --.• -- r... - - - ., <br /> . . OTHER <br /> Received by k - Uate Rece+pt No. Permit No. - Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES) 11601 E.HAZELTON AVE.,P.O.Doi 2009 STOCKTOK CA 95201 f. <br /> ' A <br />