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f Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.
<br /> r4 APPLICATION
<br /> -=r (For Non-Transferable, Revocable, and Suspendable) SEPTAGE
<br /> k ENVIRONMENTAL HEALTH-PERMIT
<br /> LIQUID WASTE
<br /> F
<br /> Applica ion is her by made to4car �n business in the jurisdictional area of th@S�n Jo Local Health District,
<br /> H Business Name (DBAj Address
<br /> z Owner L_ Address
<br /> J Firm Partners, Addresses aTelephone Numbe rs
<br /> aBusiness Telephone No. - k y= Emergency Telephone No.
<br /> Contractor Licence No. Cl
<br /> - -
<br /> ..,L-App cants Nam_e,(Print) Title s y ate F,
<br /> Please check Applicable Category (1-7)and Fill in the Required Information wYy, -,: .:, ti3 .�+
<br /> 1.-❑-PUMPER VEH1 LE.PERNIhT REGISTRATION (FOR EACH VEHICLE) 4
<br /> For July 1,r �� 'June 30,`19 F •- _: Disposal Sites - -- i
<br /> E
<br /> Description(Make/Yr., Color)
<br /> Serial No. CAL. License No. � CAL. License Renewal No..
<br /> Capacity 'Gal;Weights &Measures-No.- - -
<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 _ r
<br /> R.S. or R.C.E.Name +-- , ,R.S_bo R.C.E. No.
<br /> `'-4 Test Date/time
<br /> Test Location �
<br /> 4. ❑ SANITATION PER I I
<br /> Job Add /L cation }
<br /> �PERMANENT
<br /> Owf ; a�� Address ❑SEPTIC TANK •�:CESSPOOL ,LEACHING FIELD EEPAGE PIT PACKAGE PLANT
<br /> % ..0 TEMPORARY ❑ NEW �REPAIR ❑ OTHER
<br /> 5. ❑ CHEMICAL'.TOILETS For July 1,-June 30, 19 t
<br /> f
<br /> Type Construction' Disposal Site mm I
<br /> No. of Units Equipment Storage/Cleaning.Location(s)
<br /> r-�y,, ,.
<br /> 6. C1
<br /> Operator (REATMENT PLANT For July 1, -June 30, 19 €
<br /> Where,Certified ! `
<br /> i
<br /> Plant Location% a
<br /> Plant Capacity, + No. Units Served
<br /> ti , �tia
<br /> 7. ❑ LAUNDiiY:1For July.1,.-June 30, 19 - � ��
<br /> ❑ More Than 1,000 S
<br /> SIZE: ❑ Less.Than 1,000 S,gaFt., q. Ft. t
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.
<br /> .140"*WNW cert#if'fyyrthat in the perfarrnanceott owork for wwchthis per mifisissued,fsltia[Inotemployanyperson
<br /> in such mariner as to.becolne5ubject to workman's compensation lawsot Cafitornia.' I - I ' ,
<br /> Cantractor;a hkinq nr:,sub-eaneracung signaf ire cerefies Ow tobovdnW "1 Certify thatln the perfArMaMv of the woTk for which ibis permit is issued,I shall
<br /> employ persons subject to wofkMari s compensation laws of CatlfolttW,r, Y'
<br /> r_ I hereby,certl t have prepared l is application d that the work will be done -accordance-with San Joaquin County ,.r-•
<br /> ordinari , tate law , nd r es and re ulati s of the an Joaq Local Health District. ! s -
<br /> .�4
<br /> APPLICANT'S SIGNATU
<br /> FOR DEPARTME_NT USE ONLY !� `
<br /> -;-
<br /> Fee Is clue:{❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31
<br /> F t BILLING REMITTANCE $ 11REMIT
<br /> ! BASE EXPLANATION AMOUNT DUE CHECKED
<br /> i
<br /> DATE DATE REMITTED AMOUNT
<br /> FEE
<br /> LESS {r
<br /> s PRORATION - -r w4'• 'ti -:i-.::.2'.a # .
<br /> PLUS f
<br /> PENALTY' S .air« a.r
<br /> OTHER
<br /> L � r
<br /> OTHER 1
<br /> i
<br /> /e)r.v y ! I Date Receipt rvo., } Permit No, �l .1 w Issuance Date Mailed Delivered I
<br /> AP ICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES "'� 1601'E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 M
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