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Applications Will Be Processed When Submitted Properly Completed. Be SureTo signTneAppncazw"- <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> I ENVIRONMENTAL HEALTH,PERMIT <br /> LI ` <br /> ' Applic n is hereby ma a to airy o busine i the jQUID u ' WASTE dictional area of the Joa 'in Local Health-Distri <br /> w "Address <br /> Busine ame (DB <br /> aOwn _. Address <br /> Firm Partners, Addresses and Telephone umbers <br /> i Q, Emergency Telephone No. <br /> IL <br /> Business Telephone No. <br /> 1 Contractor Licence No. �Z u - 4 <br /> Title Date j <br /> a Applicants Name,(Print] <br /> Please check ApplPcable� + <br /> Lgory _ �� ` <br /> i ' gory ( }1-7 and Fill in a Required Inlormatio :� t;.n _ ;�� <br /> 1\❑PUMPER VEHICLEzP�MIT REGISTRATION (FOR EACH VEHICLE) <br /> PsrJu�jy 1�` ` June 30,190 -:Disposal Sites <br /> .v}. .•kw: -: <br /> y Description(Mdke/Yr:,_Color) ' <br /> Seri tv w.1 CAL. License No. CAL. License Renewal No. <br /> Capacity TrGAl,,,`Weights & Measures No. qy <br /> a-, <br /> Equipment Parking Address <br /> = 2. D UMPER YARD * <br /> .�ForJuly,i`h* �Ju e30,0J ---- ' <br /> No. of Vehicles Stored _ <br /> k <br /> No. of Chemical Toilets Stored <br /> i 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> i Test,,,L HPAA <br /> tion Test Date/Time <br /> 4. 1� SANITATIQ I PERMIT p L� �� J p <br /> Job Address/Lo tion - I' z` � <br /> Address <br /> r� <br /> Oer PACKAGE PLANT' <br /> LJ SEPTIC TANK ❑ CESSPOOL` LEACHING FIELD ( SEEPAGE PIT ❑ OTHER ^ <br /> PERMANENT ❑ TEMPORARY UK EW ❑ REPAIR 4: <br /> 5. ❑ CHEMICAL.:TOILETS For July 1, -June 30, 19 <br /> Type Constructions <br /> .- ..4 Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE YREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location A. <br /> Plant Capacity ' No. Units Served <br /> 7. �LAUNDRY For July,1, -June'30, 19 <br /> SIZES ❑ Less han`1;000 SqL Ft., ❑ More Than 1,000 Sq. Ft. <br /> 1?4DRY CLEANING, Chemicals Used/Amount/Mo. # <br /> tlomeawIrorli-ceneBda9 rst'asigr'at"r°ce'Hfiestl+etoi!°u"tt9g:"Icertifvtfi�t;ntheperforrnanceoftheworkforwhtchthisnermitisissuet4.lshaitnaiemplayanype <br /> in such manner 0"to became subjW to workman's c0fr4wiisatlan taws of Ga l€n,rii <br /> Contractor's hir►rrg w aub contracting sigltature eerdtiea the tullwvirEg: 1 ceridy that In the performance oithe wnrit for which this permit is issued,l shall <br /> employ peon subject to workman s compensation laws of California:' <br /> here certify thatLii have prepared this application and that the work will be done in accordance <br /> I with San Joaquin County <br /> bhere r ces,State laws, an ules and re latio of the San Joaquin Local Health District.ordina " ! <br /> 3 <br /> -APPLICANT'S Si AT_U -E X F <br /> _ - <br /> E_ <br /> _ FOR DEPARTMENT USE-ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER 8�T ❑.EACH .❑ January 1 &,Received By,January 31 ❑ July 1 &Received By July 31 <br /> �! REMIT <br /> - - BILLING REMITTANC e,. $ AMOUNT DUE CHECKED <br /> ' BASE EXPLANATION 'YF_ REMITTED - AMOUNT - <br /> �..�w.�-.,. .cam�i�r DATE '� ,.DATE � ' '. J S <br /> FEE � _,�� - - � <br /> LESS <br /> PRORATION <br /> PLUS ? <br /> PENALTY - - - <br /> OTHER V � <br /> OTHER e <br /> Received by Date Receipt No. Yerfnit No. Is ance to Mailed Delive <br /> red <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTALHEALTHPERMIT/SERVICES - -7661 E.HAZELTON AVE.;P.O.Box ZOU9 STOCKTON;CA 95201, <br />