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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTie Application <br /> • <br /> APPLICAfi1ON i <br /> s = (For Non-Transferable,Revpcable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE - <br /> Application is eby made carry o usiness in a jurisdictional area of th San oaquin Local Health-District <br /> is#rict <br /> FBusiness Name (DBA) ' Address <br /> z Owner <br /> a Address, <br /> Firm Partners, Addresses and Tel phone Numbers <br /> a Business Telephone No. 6`" 2607 .+ <br /> a p. _ Emergency Telephone No. <br /> Contractor Licence No. 3 <br /> L Applicants Name (Print) Cl =f Q - <br /> Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> I. El PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) € I <br /> :For July 1,- . June 30, 19 � .� _Disposal Sites r <br /> Description(Make/Yr., Color) <br /> Serial No. """9 CAL. License No. CAL. License Renewal No. <br /> Capacity' Gal., Weights & Measures No: <br /> Equipment Parking Address, <br /> 2. ❑ PUMPER YARD ' ' <br /> _ I <br /> For July 1, `June 30, 19 ( ? <br /> t- <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> s <br /> R.S. or R.C.E. Name R.S. orER.C.E. No. i <br /> Test Location Test pate/Time <br /> 4. ;K SANITATION PERMIT <br /> Job Addr s ocat'on <br /> Owner <br /> Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD X-SEEPAGE PIT ❑ PA KAGE PLANT _. <br /> PERMANENT • .❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER I J <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 ( � <br /> Type Construction Disposal Site- <br /> No. of Units Equipment Storage/Cleaning Location(s) ' ) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 i <br /> Operator Name <br /> Where Certified. $ <br /> Plant Location <br /> Plant Capacity N1. o. Units Served <br /> 7. El LAUNDRY For July 1, -June 30, 19 _ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. �� t, r t <br /> ❑ DfY CLEANING, Chemicals Used/A'rrlount/Mo. <br /> f. pmeewrrarprReentedagent'ssignaturecertifiesthefotlowinq:"Icertifythattnthep+erformanceofthewarkforwhichthispermitisissued,Ishallnotemptoyanyperson <br /> #m such manner as to becol le subject to workMfn;s tq+hpensatian ta>f s of Oa'itrn<ia." <br /> !Contractor'sphiring t t sub-contra signptor�ecertifles thq tofiewin9; A,GeTlity that in the performance of the work far which this permit is issued,I Shall <br /> employ persons subject to►vorknlan s compensatloh laws of California." _ y <br /> I hereby certify that-I have prepared this application and that-the worts will be done-in'accordance with San Joaquin County <br /> ordinances, state laws, and rLAs and re ulati s of the n quL1 o I Health Qptrict. <br /> APPLICANT'S SIGNATURE X <br /> %11� L1__� 12 014-- <br /> FOR DEPARTMENT USE ONLY t j <br /> I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jay 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> AMOUNT DUE CHECKED d <br /> DATE DATE - REMITTED # AMOUNT 9I <br /> FEELESS <br /> • ✓ Imo' S s_ -. - e._ y,, _ ��C t 1 <br /> PRORATION <br /> PLUS <br /> I PENALTY U l OjL /I / i <br /> OTHER �Q ' <br /> ¢ <br /> OTHERS-^ <br /> Received by Receipt No.- Permit No. ,' Issuanc Date Mailed Delivered <br /> 'APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 05201 ,' <br />