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Applieauons Yvin we rruveizmw+ - <br /> APPLICATiONr <br /> (For Non-Transferable;Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT' <br /> ' LIQUID WASTE _ <br /> i Application is y made terry on business in the jurisdictional area of the'San.Joaq,.uirr Lo cal Health District <br /> rn Business Name ( A) <br /> Address .— � c� •� <br /> z Owner , - _ � � � �' . - Address- r7 <br /> A <br /> Firm Partners, Addresses and`Telephone Numbers <br /> J. Business Telephone No. y erge, cy T - <br /> Ern n elephone No <br /> Contractor Licence No. <br /> Applicants Name (Print) — Y a- -_Title — <br /> Please check Applicable Category.(1-7)a nd Fill in the Required Information <br /> v, <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ,} <br /> For July 1, _ -,June 30, 19= - _ Disposal Sites — <br /> Description(Make/Yr.,Color) — <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity _ ���= —'�G` -,Gal::Weights & Measures No. -J <br /> "' <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 _ <br /> No. of Vehicles Stored <br /> 77 <br /> No of Chemical Toilets Stored -- - r <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name I R.S. or R.C.E. No. <br /> Test L cation —_— - Test Date/Time - <br /> 4. SANITATION PERMIT <br /> Job Address/Location <br /> Owner — 6l > Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ,/71K,,<EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW �EPAIR ❑ OTHER C <br /> s. ❑ CHEMICAL TOILETS For July 1.-June 30, 19 <br /> Type Construction _ G Disposal Site . <br /> No of Units f — Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1. - June 30, 19_ <br /> ,; ! _.Where Certified — <br /> Operator Name <br /> I <br /> Plant Location _ <br /> _ <br /> 1' No. Units Served <br /> Plant Capacity — F <br /> 7- ❑ LAUNDRY For July 1, -June 30, 19 ---- <br /> SIZE: ❑ Less Than 1.000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home owner or licensed agent's signetureeertifiesthe following:"'Cer!iivthe; <br /> als^" .arlcr�t nc5oi?h <br /> 11 ";erkfc -ill ll thispermi'isissaed,lshallnotemp`.oya�typerso,l <br /> in suc; manner as to become subjoct to workman's coarlsnsation:aws ct Ca(ifer?,e C <br /> Contractor's hiring or sub-cnntractlnq signature certHias thz fnlluyring: I certif that in ire perfDriti' !ice ti:t!'.e`.vcrk for wbich'.nis perrnit is i5�u0u.1 shdli � <br /> employ persons subject town rkman's conopensatian laves of Ca forma" <br /> 1 hereby certify that'I have pre ared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws. and r s nd reg ations he San Joaquin Local H atth District. <br /> APPLICANT'S SIGNATURE X -- ' <br /> FOR DEPARTMENT USE ONLY. ., . <br /> Feb IS DUB: ❑ AN NUALI Y ❑ PER UNIT ❑ PER SI f E ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> - E%PLANATION Bit LING RFMITTA'NCE" 3 AMOUNT DUE CHECKED <br /> WASE <br /> . DATE DATE YEMITT D AMOUNT+�+•r--- <br /> FtE C �aH <br /> LESS <br /> PRORATION <br /> PLUS -- <br /> PENALIY —+— <br /> OTHER <br /> OTHER i [ 4 . —�_- <br /> I �.. <br /> �3 l� <br /> - ---"- — - Permit No. Issuanc Dat Mailed Delivered <br /> Received by � Date � Receipt NOt - <br /> - APPLICANT-RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES 16ol E.HAZEL-TON AVE_,P.O.Boa 2009 STOCKTON,CA 95201 <br />