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Applications Will Be Processed When Submitted Properly Completed. Be Sure To 51gn i ne wpp+Icuuure. <br />APPLICATION <br />a (For Non-Transfirable, Revocable, and Suspendable) SEPTAGE <br />t <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />Applic n is hereby made to rry on busines int a jur' dictional area of the Sa Joa in Local Health Dis ict <br />Address <br />„Business me (D <br />! <br />Owner Address <br />j Firm Partners, Addresses a �Tel�ephone Num ers <br />iBusiness Telephone No. _- __-Emergency Telephone No. <br />�j , <br />Contractor Licence No. — <br />W• Date <br />—Title: <br />L Applicants Name (Prig t) <br />Applics Celt ory (1-7) and Fill in the Required Inlormatlon r <br />T` <br />Please check <br />11 Cj•fUMPER-VEWICLE.PERMIT REGISTRATION (FOR EACH VEHICLE) <br />Fof'July 1, ° ?` • June 3U„ 19• Disposal Sites <br />! <br />Description•(Make/Yr., COior)- CAL. License Renewal No. <br />. '.)r.3 "�-, is ^ N CAL. License NO. <br />Serial No. • • <br />---Clapacity = - -•- --Gal;; Weights 8• -Measures -Nor-- •• - - -` r I <br />`Equipment Parkili'gAdresi <br />2. ❑ PUMPER <br />-'YARD,is� <br />June 30-1:9For July t- <br />1 <br />No. of Vehicles Stored <br />No. of ChemiCal Toilets Stored <br />3• ❑ PERCOLATION TEST h <br />R.S. or R.C.E. No. i <br />R.S. or R.C.E. Name I <br />Test Date/Time <br />Test Location <br />4. ff SANITATION PERMIT <br />I ` <br />Job Addres Location 7. <br />Owner11I OF — Address <br />❑ PLAN TI <br />�� LEACHING FIELD SEEPAGE PIT PACKAGE ,.•-ma <br />LEA13y <br />M'SEPTIC TANK ❑ CESSPOOL r <br />G PERMANENT ❑ TEMPORARY C�1gEW ❑ REPAIR <br />L <br />❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br />b <br />ype Construction i _ z-DisposalSite=--- [ ; <br />Equipment Storage/Cleaning Locatian(s) <br />No of. Units - -1111 For July 1.,=�June43{;�19 } <br />,❑ TREATMENT ON � =� <br />6. PACKi4GE PLANT ( „i Where Certified <br />` Operator Name"'� •- <br />t Plant Location ` No. Units Served <br />Plant Capacity <br />7. ❑ LAUNDRY For July 1,-Oune.30_1,9.� <br />❑ T 1,000 Sq_ Ft. t <br />SIZE: 13 Less Than 1,000 Sq. Ft.. More an �� f,., ,�. i <br />❑ DRY CLEANING, Chemicals Used/Amount/Mo. �-� " _,. _ . ... <br />signature certifies thefioll0wmg: "I certiN that In Mt8 Pertafm2nCe of the work toy Which this �e�nsifi� issued. i ShBH not employ any person <br />Homeowner or licensed apent•s <br />in such manner as to become subject to workmar.'s compensation laws of ft ilornia." <br />"i ceriif haat Ir+the performance of the work for whicfi+this permit is issued, l shalt <br />Contractor's hfrior sub -contracting s+ttnatwe certifies tse :ollowing: j <br />to VO'kntari 5 compensaN;i, lavii� of Colitumi a:' <br />Ith <br />employ persons sub ect <br />and that the work will be done in accordance San Joaquin County <br />this application <br />I hereby certify that I have prepared , <br />the San Joaquin Local Health District, I <br />f ordinances, state laws, a rules and re do of <br />APPLICANT'S SIGNATURE X l� ' <br />jF +✓ <br />l <br />1 DEPARTMENT USE ONLY <br />FOR <br />' EACH ❑ January I & Receive d_By nary 35 ❑ duly 1 8 Reserved 8y July 31 <br />Fee 13 Due: ❑ AN PER UNIT ❑PER SITE ❑ E REMIT <br />BILLING REMITTANCE f AMOUNT DUE CHECKED <br />BASE EXPLANATION DATE DATE R£ T E AMOUNT <br />' <br />FEE <br />LESS <br />PRORATION <br />! <br />PLUS <br />I <br />PENALTY <br />OTHER <br />OTHER, - <br />Delivered <br />r <br />ceived by Date Receipt No. .'"",. ,..,. 1601 E_ H <br />APPLICANT=aETLIAN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />- A2ELTON AVE, P.O. Box 2003 STOCKTON, CA %26 " <br />