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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> and Suspendable) SEPTAGE <br /> (For Non-Transferable,Revocable, <br /> k J <br /> ENVIRONMENTAL HEALTH PERMIT / <br /> LIQUID WASTE <br /> Application is hereby made to carry onbqlSIness in the urisdictional area of�the�San Joaquin Local Health District <br /> O Business Name(DBA) ,pAQ?1 �� '�.� Lie Address,�'�" ��?d <br /> i Owner Address --- <br /> Firm Partners, Addresses and Telephone�Numbers <br /> aBusiness Telephone No.. lP�P= C?O� - Emergency Telephone No. - -_ <br /> Contractor Licence No. <br /> Applicants Name (Print) 's <br /> Pleas*check Applicable Category (1-7)and FIII In the Required Information. <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, - June 30,19 - } Disposal Sites _ <br /> Description(Make/Yr.,Color) i <br /> Se{ial-No.- — — - i CAL. License No. - --•- CAL. License Renewal No.,—- <br /> T — - <br /> Capacity i Gal.,Weights &Measures No. -- _ <br /> Equior>vent 1' rKingAddress <br /> It <br /> 2. ❑ PUMPER YARD t ti <br /> For July 1`1" 1 June 30, 19 + `� �. <br /> No.of Vo_l isles-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 /> .,,�,.�....�.-..•-�,,..,.�.._....�.�..,. _.. " <br /> Tt L cationt Test Date/Time <br /> ' I R <br /> 4.; SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address, <br /> ❑ SEPTIC TANK ❑T CESSPOOL EACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ,PERMANENT ❑ TEMPORARY ❑ NEW /REPAIR ❑ 1OTHER <br /> 5.. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction 1 Disposal Site <br /> No.of Units l t Equipment Storage/Cleaning Locatiori(s) <br /> P f <br /> 6.' C3 PACKAGE TREATMENT PLANT For July 1. -June 30, 19_ it <br /> Operatolir Name WLere Certified <br /> Plant Location ! <br /> Plant Capacity i No. Units Served I <br /> 7.� ❑ LAUNDRY For July 1,-Milne 30, 19 <br /> SIZE: ❑ Less than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals_d/Amount/Mo. { <br /> I Home owner aTGcensedcorttf:asthofohowino:•'Irertifythat intile performance afthcIvor kfcrvihiehthis nermitisissued,tshall not ernplay any persin <br /> in such mannor as to become sylfjedt to workmen's rr,m;I•"^salioo Ir: S of <br /> 1, Contractor's hiring or sub•cw1racJm signptcrc ar.:!�i:cs thc• "I certify that in the performance of the work for which this permit is issued,t shall <br /> employ persons subject compensatic n"laves-of Caiitornia.'• I <br /> I hereby certify that 1hav p pared this application and tha he work will be done in accordance with San Joaquin C&rnty ) <br /> } ordinances, state laws;► d r and regulatic f the S quin Loc ealth District. 1 4 <br /> ( yq -T CRS S <br /> APPLICANT'S SIGNATURE <br /> S FOR DEPARTMEJTIUSE ONLY <br /> t[ ` s <br /> 1 Fee Is Due: 1:1ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Janua(y 1&ReteivedHy 45nuary 31 ❑ July 1 8 Received By July 31 <br /> REMIT �. <br /> BASE EXPLANATION �BIL•LING�� •ITTANCE `;` f' Z AMOUNT DUE CHECKED <br /> DATE DATE REMITTED - AMOUNT <br /> I t1T 1 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> i <br /> i OTHER • , - <br /> i . <br /> OTHER <br /> Received by Date Receipt No. Permit No. Isa ante m a Mailetl Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE P.O.Bo:2009 STOCKTON.CA 95201 <br />