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Applications Will Be Processed When Submitted Properly Completed. BeSureTosign 1neRppllca�wrr. <br /> F APPLICATION <br /> � �„ � (For Non-Transferable, Rl:vocable,-and Suspendable) SEPTAGE <br /> . ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on busindw in the jurisdictional area of the San Joaquin Local Health-District <br /> Business Name (DBA) <br /> Address 4r �B e <br /> qOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. S- Emergency Telephone No. <br /> Contractor Licence No. pate S7- <br /> Applicants Name (Print) Title <br /> Please check Applicable Category (1-7)antl Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 - Disposal Sites <br /> Description(Make/Yr.,:Colo) <br /> CAU.LicenseNo. CAL. License Renewal No. <br /> Serial No. <br /> l ,We <br /> Gal - ight &Measures No. x <br /> Capacity. <br /> Equipment Parking Address; <br /> 2. 0 PUMPER YARD f "V{ <br /> For July 1, June 30, 1,91-"., <br /> . i ti Mr <br /> No. of Velhicles Stored y '' <br /> No. of Chemical Toilets Sto�'ed ,� '• \' ti <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name ( R.S. or R.C.E. No. <br /> Teshocation �' ) I Test Date/Time <br /> 4. SANITATION PERMIT .5 G� <br /> Job lAddress/Location 2- <br /> Owner �4y� I fr �# Addressers✓ y m <br /> LEACHING FIELD SEEPAGE PIT CO3 PACKAGE PLANT <br /> SEPTIC TANK ❑_CESSPOOL 11 OTHER <br /> PERMANENT ❑ TEMPOR'ARY t NEW <br /> REPAIR <br /> c' <br /> 5. I] CHEMICAL`,TOILETS For July 1,- ue 30; 19 <br /> I; ' f`a li�-,EDisposal Site <br /> I Type Constructions <br /> r No. of Unitd # Equipment Storage/Cleaning Location(s) <br /> ' <br /> 6. ❑ PACKAGE''REATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name; 1 <br /> Piarit Location } �, <br /> Plant Capacity { �" ( _ No. Units Served <br /> 7. ❑ LAUNDRY ' For,"July�1, -June 30, 19 <br /> SIZE ❑ Less Than 1,000 Sq. Ft., 11 more Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. ` <br /> Home ownerorrtcenseiagent's si�noterecokfiestho follo+rrin-3:1 crrtifyYh�'i^the per€ermanceo`the work fcr!vhich this permit is issued,l shall not 2mplayany person <br /> In SUCK manner 251'0 bE mC SUJjL'�I?L•Ulf�7iric S ccm,.ens8tin ln�':::Ot�:iit�';�i f`��2 <br /> Contractors 1 hiring o szb•^ontra,fin" si.; a;um eer.i5c tia ia;:o�>End: "'I certi iy ihat in 1"i a perlcnrsance Of t;la.work i6r which,this permit ss issued,t shall <br /> employ pers6ris su4ject worknan's c6mpar,s`tion lairs o€Caiil rni`a." <br /> - <br /> his application and that work will be done in accordance with Sart Joaq"uin County <br /> I hereby: certify tf"%t­I-%,-e p 'ed t pp <br /> ordinandes, state laws, and rules and regulations of the San JCaquinocal Health District. <br /> APPLICANT'S SIGNATURE X <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PERUNIT--_ ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 " ❑ July 1 &ReceiveRdEBy July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> -FEE <br /> LESS <br /> PRORATION l <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Perrnit No. Issuance a Mailed Delivered <br /> 1501 E.HAZELTO P.D.boa 2609 570CKTON,CA 95 <br /> 201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVI1WNMENTAL HEALTH PERMIT/SERVICES ., <br />