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Applications Will Be Proa When Submitted Properly t:ompietea. tie sur bign i ne Application.
<br /> 'te
<br /> , 7 APPLICATION
<br /> (For Nor-Transferable, Revocable,and Su spendable,,tet SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> j LIQUID WASTE
<br />!I Applica Is hereby made to car op bu " ss in
<br /> N uri ictionalAdrderaeosfs teSgJLocal
<br /> -Health District
<br /> Busin ame(DB � a
<br /> A
<br /> sem- ------ �
<br /> aOwn - Address
<br /> Firm Partners, Addresses and Telephon Num ers
<br /> 1LBusiness Telephone No. (z, Emergency Telephone No.
<br /> Contractor Licence No. Z ZZ
<br /> L Applicants Name (Print) Title Date
<br /> Please check Applicable Categ 0-7)and,Fill in the R uire�Inform�aftn
<br /> 1. ❑ PUMPER.VEHICLE PERMIT,REGISTRATION (FOR EACH VEHICLE)
<br /> ForJuly 1, June 30, 19 Disposal Sites
<br /> Description(Make/Yr.,Colory
<br /> Serial No- CAL. License No. CAL.License Renewal No.
<br /> Capacityf— Gal.,Weights &Measures No.
<br /> 'Equiprtient Parking Address'
<br /> 2. ❑ PUMPER YARD
<br /> l or July 1, Juge 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.or R.C.E. No.
<br /> Test Location 3 - ` est Date/Time
<br /> vd
<br /> 4. L7 SANITATION PER TI,fLP N
<br /> Job Add r s/Location +"' I }4
<br /> Owner Address
<br /> � SEPTIC TANK C1'CE POOL ❑ LEACHING,FIELD ❑ SEEPAGE PIT ❑ �CKAG �L NT
<br /> B'PERMANENT ❑ "TEMPORARY. ❑ NEW IE-IMPAIR fR _
<br /> 5. F-1 CHEMICAL TOILETS For July l; June 30, 19" pd
<br /> Type Construdtion Disposal Site r
<br /> 3 No. of Units Equipment Storage/Cleaning Locatlon(s)
<br /> Ill s
<br /> 6. ❑ PACKAGE TREATMENT PLANTa For July 1 dune 30, 19 t L V
<br /> Operator Name Where Certified
<br /> Plant Location
<br /> "Plant Capacity." = r- No. Units Served - ' -
<br /> I 7. ❑ LAUNDRY For July 1,-June 30, 19
<br /> SIZE: 13Less Than,1;000 Sqx Ft., ❑ More Than. {t00 Sq:-'Ft..
<br /> t.
<br /> ❑ DRY CLEANING,Chbmicals Used/Amount/Mo. .-
<br /> Herr*owner o.licensed eOrWs sipnatare cartifiba thefoflowing:'I certitgthat in the performance of the work for whichthis permit is issued:l sfiall not employ any person
<br /> in such marin.0 a.�to becomr sull(eei t.r wori!man'e 17evs rt-,G hf
<br /> coctrictoc s 1;cinq ur s.6-contracting s w•ri',,u._m_ esr;o,:-, failed: i cAr;f'.;'„a;'i-,tilc Gar#oi:;a, ;o rhe cvvri,for whiefr t`ais perrcii is issued,I sha'.l
<br /> C't'F'JL p sa,l__'AgrA I,, .l.,- _i:r5:,3-ti;i'_n.,,of;.:ti.....,..�..
<br /> I � ,
<br /> I hereby certify that I� have prepared this application and that the work will be done in accordance with San Joaquin County
<br /> i ordinances`sTate laws,a d rules and re ulati ns of the San Joaquin Local Health District.
<br /> APPLICANT'SISIGNATURE X I
<br /> 4 !`
<br /> w
<br /> -F R`DEPARTMENT USE ONLY
<br /> Fee IS Due; ❑-ANNUALLY _._0 PER UNIT' PER SIT ❑ EACH ❑ January t&Received By January 31 © July 1 &Receiied Sy July 31
<br /> •' BASE ERPL•ANATION,” BILLING REMITTANCE $ AM(?IN DUE CHECKER
<br /> } DATE DATE REMITTEEI /AMOUNT
<br /> l LESS
<br /> f[ PRORATION
<br /> PLt�S;
<br /> - PENALTY -
<br /> 4 .
<br /> OTHER:
<br /> OTHER'I
<br /> r.
<br /> Received by - .Dafe —Receipt No. Permit No. ssuance Date Mailed Delivered
<br /> APPLICANT=RETURN ALL Co,PJES TO, ENVIRONMENTAL HEALTH PERMIT/SERVICES.. --• 1601'E:)RAZELTON'AYE:,'P:_O.ank.2009�-•--STOCKTON,CA 95201
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