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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 /> G LIQUID WASTE <br /> Applica is hereby made t carry n busin ss in t e' risd' tional area of the S J aquin cal Health District r <br /> HBusiness ame (DBA Address <br /> aOwner Address <br /> Firm Partners, Addresses and Tele hone, NJumb rs _57710 57T <br /> ECL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date " <br /> Please check.Applicable.�C -gory(1-7)and Fil the Required Information _ <br /> 1." 0',P,UMPER-MEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For Ju y 14 June 30;-1,9 Disposal Sites <br /> v ti <br /> Descl iption(Make/Yr..",Color) <br /> Serial No..—'`- '� '• - CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> SEquipment.Parking Addr'Oss--�' <br /> 2. 1:1 PUMPER YARD <br /> ,For44 <br /> July'1; June.30, 1.9 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilels Stored <br /> i <br /> 3. ❑ PERCOLATION TEST r <br /> R.S. or R.C.E. Name R.S:or R.C.E. No. <br /> Test Lo ion Test pate%Time ``� - <br /> -4--V SANITATION_PERMI <br /> Job Addres oca 'on �� � <br /> Owner I Address \ <br /> ❑ SEPTIG TANK ❑ CESSPOOL ©L CHING FIELD ❑ SEEPAGE PIT El PACKAGE PLANT <br /> M-15ERMANENT ❑ TEMPORARY ❑ NEW &-ITEPAIR <br /> .(� <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Constructionf Disposal.Sito'. l- " •` <br /> No. of Urfits Equipiment Storage/Cleaning'Lo'cation(s) + -J <br /> t - r <br /> 6. E] PACKAGE TREATMENT PLANT For July 1,-June 30, 19 r <br /> Operator Name <br /> Where Certified. <br /> Plant Location_- <br /> Plant Capacity'. ; r �7'No.-Units,Served -r <br /> 7. ❑ LAUNDRY �For July.1, -June 30, 19 � -- <br /> +° <br /> SIZE: ❑ Lessihan 1,000 Sq. Ft., ❑ More Tharr-e^000 Sq. Ft. \ w <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Homeowrse.arli4anaedagent'rsignaturer,,art4clncths�rztlM�i1d icertiiohatinthe performance ofthe work for which INS permit isissued,ishall not employ any person <br /> in such marw6r-as to become sut�Iect to workman's aaY rper sat es la nes of Cali€crr in:' t r <br /> Contraetor:s-hiring or rub-contracting ai,naxuLc certifies the following: 1 certify that in tho performance of the work for which this pt:rmit is issued,I shall <br /> employ�ersnn-s subiect to workman's comperrsatioli lnvvs-of Cai#ornia.0 & a <br /> I hereby certify-that I have prepared this applicatidn-and the work will'be done in accordance with Sian Jo utn County <br /> ; ordinances, state laws, and rules an req lation's of the San Joo q iri Local'He6Ith District, J <br /> APPLICANT'S.SIGNATURE X r <br /> { !K± s FORDEPARTMENT USE ON Y- <br /> Feelrls Dile: ❑ ANNUALLY ❑ PER UNIT PER SITE ' ❑ EACH ❑ January 1'&'Re ive B ary 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTAN_CEt AMOUNT DUE CHECKED <br /> i BASE EXPL7 NATION DATE ATE TED <br /> AMOUNT <br /> FEES <br /> LESS <br /> PRORATION <br /> PLUS } <br /> PENALTY ' <br /> OTHER <br /> i <br /> z .OTHER <br /> Received by - Date Receipt No. Permit No. Issuaince Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAXELTON AVE.,P.D.Box 2009 STOCKTON,CA 96201 <br />