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Applications Will Be Processed When Submitted Properly Completed. BesureTosign ineAPPRwuvn. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> _ LIQUID WASTE r t <br /> Applica ' is hereby m de to ar o busin in jurisdictional area of.the aq Local Healt Distri <br /> Address <br /> aBusine ame (DB <br /> aOwne - Address <br /> Firm Partners, Addresses and-Tele hone umbers u' <br /> Emergency Telephone.hone No. <br /> aBusiness:Telephone No.. 9,.a <br /> Contractor Licence No. Z _ -- T <br /> 2 . .Date 1 <br /> Title <br /> Please checkAplicable C t ory; <br /> (, <br /> Applicants Name (Print] r :.s• , r <br /> 1,7)_- and Fill in the R_equired%!In ormation I <br /> = p . <br /> 1. ❑ PUMPER VEHICLE,PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> ForJuly,_1;= June 30;.Y9� - Disposal Sites_ <br /> r a. -t _ <br /> Description.(fiMakelYr-:;Color) <br /> > d CAL. License Renewal No. <br /> .Serial No. CAL. License No. r <br /> Capacity '.� Gal.,Weights &Measures No.' <br /> tti <br /> Equipment Parking Address € <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19'' ; <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored ) <br /> 3. ❑ PERCOLATION TEST <br /> WS. or R.C.E. No. <br /> R.S.or R.C.E. Name r - <br /> Test�,Lo Ion Test Date/Time <br /> q, i�'SANITATION PERMIT -70 . <br /> Job Addre s/Location - <br /> Ow r �TANK <br /> -.,.• �_ __ - -• :...~,.-}.".-,."`�Address`� .. - _ _ - � .� �. <br /> it <br /> Elf S PTICESSPOOL LEACHING FIELD -+SEEPAGIf-PIT PACKAGE �y <br /> I �I REPAIR 0-01HER <br /> !LS PERMANENT 11 TEMPORARY ❑ NEW <br /> 5. ❑ CHEMICAL TOILETS-For'Ju1y 1` June 30;`19' c 1 <br /> TDisposal,Site- <br /> ype Construction <br /> ;r '. <br /> No, of Units Equipment Storage/Cleaning Locations) <br /> c,K �• t <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 t-^� y` <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity i ry <br /> No. Units Served <br /> 7. 0 LAUNDRY For July 1-:`Jure 30, 19 <br /> SIZE: ❑ Less Than 11,000 Sq. Ft.,'154 More Than000 Sq. Ft. g NA <br /> ( ❑ DRY CLEANING,Chemicals Used/Arrrlount/Mo ` <br /> Homeownevorlicencedatgent'ssigrn,t�; ceft7¢esti�slvl,swings"Icertihlthatipthepe-tarma�"oftheworkforw!�iclltfaispermitisissued.ls3aallnotemployanypars^.r <br /> i to sued manner as to become subjec*[c w+�rk_,soli S.CdY1¢t PSatioq IaiM3 of Ca[iiornia.-' it <br /> Contractor's hiring ar sub-contracting signal,.ire C9rtitES th "to3lowing:--i Certify that in the performance 91 a!e work for which this permit IS issued,l shat{ <br /> employ persons subject to workman's compensation lays of California:" <br /> I hereby certify that] have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an rules an gut tions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X " <br /> r <br /> FOR DEPARTMENT USE ONLY - <br /> Fee Is Dile: El ANNUALLY ❑ PER UNIT ❑TPER SITE ❑ EACH ❑ January 1 &Received By January 31 [J July 1 8 Receiv REMITuIy 31 <br /> r BASE EXPLANATION BILLING I REMITTANCE _ $ AMOUNT DUE CHECKED <br /> Y r. <br /> DATE - DATE - REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PWS _ <br /> F - PENALTY - <br /> OTHER <br /> OTHER H <br /> Date Receipt No. Permit No. Iss once to Mailed Delivered <br /> Received by . <br /> '1607 E.-HAZELTON AVE.,P.O.Box 2099 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL"KEALTH PERMIT/SERVICES reeaAeof Ly 4 <br />