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APPLICATION <br /> (--)r <br /> r lr Non-Transterabte, Revocable,and Suspendan y SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE . <br /> pp area of the San Joaquin Local Health District; Y ,�# <br /> ,. <br /> Application lication is hereby made to carry on business In the <br /> jurisdictional area � . <br /> r Address - <br /> n Business Name (DBA) O <br /> Address. -- <br /> z <br /> ddress . <br /> Q <br /> 4U Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> aBusiness Telephone,No. ' <br /> Contractor Licence No. <br /> I mTitre Date, - <br /> Appcarits Nae (Print) <br /> Please check Applicable Category(1-7)and Fill in the Required Information F <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> Disposal Sites <br /> For _ -July 1" �I June-30,19 <br /> .. <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. m CAL. License No. <br /> Capacity <br /> t Gal Weights &Measures No. <br /> -*.Equipment Parking Address_ F <br /> 2. ❑ PUMPERNARD' I <br /> For July 1, June 30, 19 <br /> No.'of Ve 'clew Stored <br /> No. of emical Toilets Stored <br /> 3.;" PERCOLATION TES <br /> !� ��iN.� - R.S. or R.C.E. No. <br /> R.S.or R.C.E. Name,, � ur �4Nryk-�t <br /> Test Location`_c'z� £�A Test Dato/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner, Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT 0 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL`TOILETS for July 1, -June 30, 19 <br /> Type Construction k Disposal Site - <br /> No.of Units Equipment Storage/Cleaning Location(s) r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY `For July 1, -June 30, 19 <br /> SIZE::, ❑ Less Than 1,400 5q. Ft., ❑ More Than 1,000 Sq. Ft. _ <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> V Ov"ownerorliceozetlagertt's neturecartiNesthefatlowing,1cerflhrthat Witte performance olmework for vrhichOispermit isissued.1S,%r!lnot emplay any person <br /> in such manner as to become subject to workman'b cotripsitsation iav-s ot�a4iforr:;., <br /> Cont"Itotrs hiring er -b-eontrscNng sigrotme conFHes she 'Eosiowirax;. T cerlify that#,t the pertatmancc of the work for whiathis permit is[sired,I shall <br /> employ persons su4jec1 to workmans compensation laws of Calito(Aia." <br /> ' °* I hereby certify that I havepreparedthis application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an s a regul 'ons of a San Joaqui Local Health District. i <br /> ARPLICANT'S SIGNATURE X _ <br /> 7 —�lC% <br /> �L, ve iyv <br /> FOR DEPARTMENT USE-ONLY •- <br /> r <br /> Fee Is Due: ❑'ANNUALLY _❑ PER UNIT PER SITE Cl EACH 0 January 1 B Received By,January 31 © July'F &ReceiveRdEMIITuIY 31 <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CNEOKED <br /> DATE: DATE REMITTED AMOUNT <br /> - 5a�00� 540 O <br /> x <br /> FEE­ <br /> 'LESS c LESS <br /> ' PRORATION { - <br /> y IPLUS a <br /> I PENALTY <br /> OTHER <br /> OTHER. <br /> 14, <br /> Received by :,• Dates _Receipt No. Permit No. issuance Date Mailed Delivered <br /> APPLICANT— TURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES 1fi01 E.HAZELTON AVE.,P.O.Bae 2009 STOCK70N,CA 95201 <br />