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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 /> ENVIRONMENTAL HEALTH PERMIT <br /> rr LIQUID WASTE <br /> Application is hereby ma a to carry on business in he jurisdictional area of-t an aquin.Local Health District•.., , r <br /> OF Business Name (DBA) iC *� ,Address � d (p`7: G'LclA I v <br /> z Owner �� +..:..:_ Address W <br /> a _ . <br /> Firm Partners, Addresses and Tele hone Numbers <br /> CL <br /> Business Telephone No. � � �'�,�• - --- - Emergency Telephone No; I�J <br /> r Contractor Licence'No. Z •- > <br /> L Applicants Name(Print) >_ Trtle Date _ I <br /> Please cheek Applicable`.Category(1-7)and Fill in the Required Information `. L ,, Lt�; ,V s <br /> 1. ❑ PUMPER-,VEHICLE_f?E_RMIT REGISTRATION (FOR EACH VEHICLE) <br /> For-July 1; w June 30, 19 ' - 'Disposal Sites <br /> Descrpti6m(Make/Yr`Color) <br /> .Serial No. a CAL. License No. CAL. License Renewal No. . <br /> 'Capacity Gal., Weights & Measures No: +` <br /> E I ment Parkin -• w <br /> 2.,/ 1---4;PUMPER YARD <br /> r -,t: .0 ' =f7 � <br /> For July 1 , V June 30, 19'' <br /> No"'ofA eliicles Sto.reda 9• <br /> No. of Chemical Toilets Stored <br /> ' r z � <br /> 3.f❑'PERCOL'ATIO{N T?�EST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. �ANITATIQN PERMIT <br /> Job Address/Location jo 35- 4'QC <br /> Owner P ° �►" Address 1 <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEAC ING FIELD -SE� Pei, 0 P CKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW Z-11EPAIR S 4' ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS. For July 1, -June 30,.19 _ <br /> Type Construction Disposal Site <br /> No. of Units S i Equipment Storage/Cleaning Location(s) C? <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name _ -. .. :_ __ - Where Certified - fl <br /> Plant Location 3 <br /> Plant Capacity s No. Units Served - <br /> 7. ❑ LAUNDRY For July 1;-June 30,19 <br /> SIZE: Less Than.1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t�oenaorm.rorttceneedavenr•ssr sns[urseeedlfeatMfalovekq;"Icert)ivthatinthepeVorinanceoftheworkforwhichthisperrnftisissued,lshallnotehrplayanyperson <br /> In such manner aS to beca,�iy subjei:l to workman's i;crnipersatic n laws of Ca(iforma," <br /> Contrnctor•s hiring-or si!lattire cpris'ie-�;the following:.'1 Certify that i:1.he performance of the work,for.v bieh Ibis perrnft is issues,l snail <br /> +rl;;?e;,� rsons pub ect; :t r Etr;ll' L0;11NSiF3n:i liI laws*f Celi;c;rf"ja.' <br /> hereby certify that l have prepared this application and that the work will be done in accordance with�San Joaquin County <br /> ordinances, state laws, and rules and regulations of the-San Joaquin Local Health District.t_ <br /> APPLICANT'S SlGNATUREX' <br /> Ile- <br /> uFOR DEPARTMENT USE-ONLY"' `- <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received Byilanuary 31' ❑ Julyi&Reei'ved By July 31 <br /> i srF <br /> BILLING I REMITTAkEf J $ {r s REMi1 <br /> !BASE EXPLANATION tea I AMOUNT115 k CHECKED'ti <br /> DATE .��DAIE,.,..�,.�.- ...:;REMITTED ..,._..._..^.�.^"�r....K.. AMOUNTS <br /> I � <br /> FEE 4k: <br /> ir C <br /> LESS' <br /> PRORATION <br /> PLUS t r <br /> PENALTYfi <br /> OTHER . y r <br /> le <br /> _x OTHER <br /> r _ <br /> Received by DateReceipt No. - Permit No. lssuan a Date Mailed Delivered _ <br /> LL APPLICANT-RETLIRN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES' 1601 E.HAZELTON AVE.,P.O"Box 2009 STOCKTON,CA 9521311 <br />