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Applications Will Be Processed When Submitted Properly Completed. BSure <br /> APPLICATION x <br /> �- (For Non-Transferabie,°Revocable,and Suspendabie) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i her by made_to carry on business in the jurisdictional area of the San Joaquin Local Health District d r 4,} y <br /> i Address � <br /> ,�Business Name (DBA) <br /> z Owner Address <br /> Q ,�,- va .v - i:�.> .. .r,.r-its✓. Rt-r.- ;_ . ..r i:L;�.� c. <br /> `r J Firm Partners,'Address s and Telephone Numbers <br /> 1 d Business Telephone No. Emergency Telephone No. Y <br /> Contractor Licence No. Y t Date <br /> oi <br /> Applicants Name (Print) �u Title y i <br /> '7 and Fill in the Required,Information.. t <br /> Please check Applicable Category{1 )+ tcl 91111!- AL <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June-30, 19.:- "- Disposal.Sites - <br /> r <br /> Description(Make/Yr.,.Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> I <br /> Capacity Gal., Weights&Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> l For July 1, -June-30, 19 <br /> l No.of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.Name R.S. or R.C.E. No. <br /> l <br /> Test Location Te_st_Date/Time <br /> 4, ❑ SANITATION PERMIT�7 <br /> Job Address/Location., •�`'�"�! �. S <br /> Owner • Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL' ❑.LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT � 11�� <br /> ❑ PERMANENT 11TEMPORARY ❑ NEW C1REPAIR ❑ OTHER v" <br /> -5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> 'd <br /> No. of Units Equipment Storage/Cleaning Location(s) 1 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> ( Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity �No. Units Served '"��"� �' — <br /> 7. ❑ LAUNDRY For July 1, ;June 30,.19 <br /> i SIZE: ❑ Less Than 1,000 Sq. FL, ❑ More Than 1,000 Sq;Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. r a <br /> Homeowner orlicenradapent`ssignaturerortttPestf+eftisowing:"Icertifythat infh,,OrformanceMlheworkfotwhich this permit islSSI, ishallnpt'employ8nyperSn[t \ <br /> in such manner as to become subiect to workman's compensation laws Uf.CaNfnrnia." ' ; 1 F <br /> Confreator"s hiring or sub-contracting signature certifies the,foilovAnw "I certify that In the pertormance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's compensaiioR laws of California,'_ _.... .ri i r <br /> I hereby certify that l have prepared this,application and that-fhb work will be done in:accordance-with-Sara-Joaquin-County-1 <br /> ordinances, state laws, and rules and re latto s of the San Joaquin Loca+Health Distract. <br /> APPLICANT'S SIGNATURE X� <br /> 41. <br /> ------------------ <br /> �..., i F_OR DEPARTMENT USE1ONLY <br /> " <br /> Fee IS DUe ❑ ANNUALLY .❑ PER UNIT, ❑ PER SITE ❑ EACH ,❑ January 1;&ReceivedByJanuary 31 ❑ July 1 S Received By July 31 <br /> `' t �._.. REMIT <br /> BILLING r ^�EAAITTANCf a$-J t + AMOUNT DUE CHECKED <br /> a BASE EXPLANATION DATE a DATE, �.. _. REMITTJD �' - AMOUNT <br /> FEE - - 'r..-!' •w` _ - f` �. - -- "8 '' # <br /> LESS <br /> -PRORATION- - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 111 -- - " - • t <br /> _ ssuance a e Mailed Delivered- <br /> Received by Date Receipt Na- Permit Na_ . <br /> APPLICANT`'RETURN ALL COPIES TO: ,ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1681 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 9$201 <br /> ' FF <br />