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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATI`ON <br /> Non-Transferable;Rerocabie,and Suspendabli: f SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE _ <br /> Applica ' is here$y ma a to carry o usin ss' the'urisdictional.area of the an Joaqu' Local Heal}h.Distri"ct.. , <br /> FBusines ame (DBA} Address c z <br /> z Owner <br /> a Address <br /> " p <br /> ,- - - _ <br /> J Firm Partners, Addresses an Tele hone umbers <br /> cBusiness Telephone No. Emergency Telephone No._ <br /> Contractor Licence No. <br /> a i,,- .7� f c�sy <br /> LApplicanls Name (Print) r Title Date_ ~p�ov <br /> PA6esei'61heck-4plicable Cat ry,(1-7)and.Fill,in"the quired Information d j <br /> 1. ❑ PUMPER VEHICLr:,,00MIT REGISTRATION (FOR EACH VEHICLE) i)! <br /> Jul—l'.` `" June'30,•19 Disposal Sites <br /> For Jul -1, `: - <br /> Descriptiorf;(Mak%Y-c„ ColCr) J <br /> Serial{yob Y CAL. License NO. CAL. License Renewal No. <br /> Ce}6ity Gal., Weights & Measures No. <br /> Equipment Nvkin ;Add'ress <br /> yy t <br /> For June 30, 19 i <br /> fNo. of Vehicles Stored 3 <br /> No. of Chemiial Toilets Stored t <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E.No. <br /> 4Test Location" Test Date/Time <br /> i4. UKANITATION PERMIT �� <br /> Job Ad r ss/Lo at' <br /> ;Owner Address <br /> .❑ SEPTIC TANK ❑ ESSPOOL �EACHING FIELD O-SEEPAGE PIT ❑ PACKAGE PLANT. . <br /> PV' P_RMANENT ❑ TEMPORARY ❑ NEW (REPAIR ❑ OTHER <br /> 5_ ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> :Type Construction ""Disposal'Site <br /> ,No. of Units Equipment Storage/Cleaning Lrocation(s) <br /> 6. ❑ PACKAGE TREAt.MENT PLANT For July 1,,-June 30, 13s__ ;. <br /> 'Operator Name .." ------__. _.__.._._ . ..__e ,'� Where Certified <br /> ;Plant Location <br /> Plant Capacity ` No. Units Served <br /> .7. ❑ LAUNDRY For July 1, -June 30, 19' <br /> :SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More'Th, an 1,000 Sgp Ft. <br /> DRY CLEANING, Chemicals Used/AmountA, <br /> 1 <br /> Home ownero►licensedagent'ssrgnaturecertit}e5it!+B JBWpIg:"lce tdr, at intheperfarmdnceofthe work for which ihispermit isissued,Ishall-noternployanyperson: <br /> in such manner as to become subject to work*sari s'compeR, lion laws t►fCa ifornia. <br /> Cok6ctoir's hiring:.or sub-contracting sig"arture certA"05 ,Hie t<a�owir,g:.:�.1"certify that:irr the performance of the wdrk for,which this permit is issued;l snail <br /> BinpIGy persons subject to workman's compensat- n taws of Cal_afprnia:' ; <br /> hereby certify that I have prepared this applialon nd that the work"will be done-in accordance with San Joaquin County <br /> ordinarices, state laws, and rules and regulqLions ofath San Joaquin Local Health District. <br /> APPLICANT'SSIGNATURE <br /> X ' <br /> =,. FOR DEPARTMENT USE ONLY <br /> Fee IS Dile:❑ ANNUALLY PER UNIT PER SITE El January 1 &Received By January 31 ❑ July 1 8 Received By duty 31 <br /> REMIT <br /> i BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE # qr <br /> LESS <br /> i PRORATION <br /> 1 PLUS <br /> PENALTY <br /> �. OTHER - - <br /> i <br /> OTHER <br /> 5� z v <br /> Received by - Date Receipt No. - Perrn0 No. - s uance&Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTALHEALTHPERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA95201 <br /> R.--.t. I. /j / . --KA1'7' <br />