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Applications Will Be Processed When Submitted ProperlyCompleted. raesure Io wywl 111v^NN"�a•'�"' <br /> APPLICATION <br /> t (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> 4 ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health Dis rictt Q'r, C JD <br /> rn Business Name(DBA <br /> ,4' L 0 0-v �t ma k -Address R 1/i I. <br /> Address v <br /> z Owner - <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. .50�.�4�91`� <br /> `�. -�y Emergency Telephone No. - <br /> a <br /> � Contractor Licence No. r]-p7')— <br /> Title Date <br /> L Applicants Name (Print) <br /> Please check Applicable Category (1'-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) i <br /> For July 1, June 30, 19 Disposal Sites Y <br /> Description(Make/Yr.,Color) CAL. License Renewal No. <br /> Serial No. CAL. License 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 <br /> R.S. or R.C.E.No. <br /> R.S.or R.C.E. Name <br /> Test ovation Test Date/Tim&, <br /> 4 4. SANITATION PER T a J <br /> r- Job Address/Location <br /> J Address <br /> O ner 11 PACKAGE PLANT <br /> SEPTIC TANK 13 CESS POOL LEACHING FIELD ❑ SEEPAGE PIT a OTHER <br /> 11 PERMANENT 131 TEMPORARY `KNEW ❑ REPAIR <br /> _t. 1 .. t� <br /> 5. ❑ CHEMICAL TOILETS 1Jor July 1, -June 30, 19`J `' - u, CJ <br /> Type Construction _J- Dispos,al Site <br /> No. of Units Equipment Storage/Cleaning.Location(s) q <br /> 6. 13 PACKAGE TREATMENT+PLANTi For July 1,s\June 30, 19 <br /> Where Certified <br /> _Operator Name " Certified— <br /> operator <br /> f <br /> (Plant Location <br /> Plant Capacity No. Units Served - <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> CUQAt�JNG,Chemicals Used/Amount/Mo. <br /> ortcanara agent'sfiittoworcartifiesthefollowing;"Icertiiy thatin:the Performance ofthe work fo'rwhicht^isperI. mitisissued.Ishalllnotemployanyperson <br /> in such manner as to become subject to worScmari s compensation laws of Catifofnia."- <br /> Contractor's hiring or sub contracting signatUre certifies the fatlotving. 1-certify that'in the perforrllanCr ei ti19 Wdr fcr syh;ch 1h1S,er'r i:? <br /> employ persons subject to workman's campensation laws oi_{:alifornia." is issued,!shalt <br /> i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and_regulations of the San Joaquin Local Health`District. <br /> APPLICANT'S SIGNATURE X � <br /> E FOR DEPARTMENT USE ONLY <br /> I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT Cl PER SITE ❑ EACH ❑ January 1 &r,Received By-January 31•--Y ❑ July 1 &ReceiveRdEBy July 31 <br /> BASE EXPLANATION BILLING REMITTA E $ AMOUNT DUE CHECKED <br /> DATE DATE- ` .REMITTED AMOUNT <br /> FEE r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ;: •ua <br /> { OTHER - - - - - <br /> Received by Date Receipt No Permit No. Issuance Date Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Bor 2009 STOCKTON.CA 95201 <br /> APPLICANTrRETURN ALL-COPIES To: ENVIRONMENTAL HEALTH PERMITlSERYICES <br /> —. <br />