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nppncauuna nm oe rit,--roaeeu vinen ouomuteu rropeny t ompreteo. oe aure to algn I Ile nppuuauun. <br /> APPLICATION �� <br /> 60 For Non-Transferable, Revocable,and SuspendabT� SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application9'ils hereby made carryon businesJS in the jurisdictional area of than Joaquin Local Health District <br /> M Business Name (DBA)�7L-r �- �rS • -s _Address ��-� s>�le-"`� <br /> r <br /> Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a <br /> Business Telephone No. Emergency Telephone No. I <br /> _ a Contractor Licence No. <br /> Applicants Name (Pring Title -..Date G—�� <br /> Please check Applicable Category(1-7)-and Fill,in the Requ red Informatlon <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) i <br /> For July 1, June 30, 19 Disposal Sites - - <br /> r Description(Make/Yr.,Color) 1 <br /> Serial No. CAL.License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights&Measures No. <br /> Equipment Parking Address <br /> se' 2. ❑ PUMPER YAAD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S.A>orR.C.E.No. <br /> Test Location Test Date/Tifi <br /> a. 4. ❑ SANITATION PERMIT / / s <br /> Job Address/LWatign �z � /dlcr.nCS 4%.a �' BILA G.-s <br /> Owner 00 C1 Address -- <br /> tee r' SEPTIC TANK, ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE-FIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT - ❑ TEMPORARY 11 NEW I] REPAIR ❑ OTHER <br /> 5. ❑ CHEMICA4 TOILETS l or July 1,-June 30, 19 <br /> ` Type Construction Disposal Site --- r <br /> No.of Units Equipment Storage/Cleaning Location(s) <br /> -- 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 3o, 19 <br /> Operator Name - Where Certified' - - <br /> °i' Plant Location <br /> Plant Capacity = No. Units Served <br /> 7. ❑ LAUNDRY -For July 1,-June 30, 19 i- - - <br /> be SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. ` r <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> No"owra rorgoensed agent'sdgaature eertifiesthefollowing:"I certif[that in theperformance of thework far which this permit is issued.i shag not employ any person <br /> in such manner-as;to become subiac to workinari s comperrov;fo.*,.la?a`-et Cyti(1mgc __ <br /> r Contnetoes hiring or sub-contracting signature oertifies Me following: I Certify thilt in the performance of the work for which this permit is issued,I shalt <br /> employ persq_ySsubject to workman's compensation laws of California" <br /> I hereby certify that I have prepared this._application and that the�work will be done in accordance with San Joaquin County <br /> -ordinances, state laws, and rut and re if of the San J in Local Heal t trict. <br /> INS A <br /> APPLICANT'S SIGNATURE X <br /> bo FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑ PER[UNIT ❑ PER SITE ❑ EACH ❑ January t&Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE It AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> ` DATE DATE REMITTED AMOUNT <br /> FEE ty <br /> L LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER A <br /> OTHER <br /> I✓ Received by Date Receipt No. Permit No. - issiance vate Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMR/SERVICES teal E HAZELTON AVE.,P.O.0.8005 STOCKTON.CA 96201 <br />