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erly <br /> Applications Will Be Processed When SuAPPLIpCATIONe <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT a <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional Aarea of ddress the San Joaquin Local Health District O t <br /> HBusiness Name (DBA Address <br /> a Owner � D <br /> Firm Partners, A dresses and Tophone Numbers Emergency Telephone No. <br /> ro <br /> IL Business Telephone No. ytp <br /> .��. Date <br /> Contractor Licence No. vXEs Title Ia <br /> Applicants Name (Print) I <br /> Please check Applicable Category (1-7) and Fill in the Req�retorr ICLE <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FODisR <br /> EACHVEHICLE)EHICLE) <br /> For July 1, June 30, 19 f <br /> CAL. License Renewal No. <br /> Description(Make/Yr.,Color) . <br /> ♦ ' CAL. License No. <br /> Serial No. <br /> Gal.,Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address 1� <br /> Z, ❑ PUMPER YARD <br /> For July 1, June 34, 19 F <br /> No.of Vehicles Stored <br /> No. of Chemical Toilets Stored F , a <br /> 3, ❑ PERCOLATION TEST +, R.S. or R.C.E.No. <br /> R.S.or R.C.E.Name Test Date/Time <br /> Te t Location d Q <br /> q �0 SANITATION PERMIT . � STpt <br /> Job Address/Lo ation t <br /> { Address ❑ PACKAGE PLANT <br /> Owner # -LEACHING FIELD ❑ SEEPAGE PITCn <br /> �L SEPTIC TAN ❑ CESSPOOL ❑ REPAIR ❑ OTHER Q <br /> PERMANENT ❑ TEMPORARY NEW <br /> 5, ❑ CHEMICAL TOILETS For July 1,-June 30, 19 -------- <br /> 5Site <br /> Type Construction <br /> No. of Units Equipment Storage <br /> ng Location(s) <br /> Where Certified <br /> 4 g. 13 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name ► <br /> tt Plant Location r No. Units Served f <br /> i Plant Capacity <br /> i 7. ❑ LAUNDRY For July.1, - June 30, 19 S <br /> SIZE: <br /> ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,400 Sq. Ft. <br /> j ❑ DRY CLEANING,Chemicals Used/Amount/MO. leertilythatintheperformanceoltheworkforwhichthispermitisissued.I$hallnotemPloyanyperstln <br /> F <br /> Herne Own�prlicensed agent's signatureeertiliesthefoltowinaw <br /> r in such manner as to became subject IQ workman's compensation laws f GalWngr a I <br /> Contractor's Kirin j or subcontracting sigeecc,se certifies the f°Itow"'g' 'I cerGly that m the performance of the work for which this petmit is issued.f sttal <br /> r emplay persons subiect to workman's compensation laws 01 California x / <br /> d this application and that the work will.be done in accordance with San Joaquin County <br /> i 1 hereby certify that 1 have prepare uin-L•ocalYHealth Distrlc <br /> ordinances, s 'ons of th San Joq. <br /> tate laws, and rules and regul <br /> f APPLICANT'S SIGNATURE �u <br /> ) FOR DEPARTMENT USE ONLY <br /> f <br /> - r REMIT <br /> 4 Fee IS Due; ❑ ANNUALLY ❑ PER UNIT .�PER SITE EACH ❑ January 1 8 Received By January 31 ❑ July 1 & c�Jed Suly 31 <br /> AMOUNT DUE CHECKED <br /> XPLANATION <br /> I • BILLING REMITTANCE REMITTED AMOUNT <br /> BASE .EDATE DATE <br /> 0 <br /> Ir FEE <br /> r LESSG� I4111-. <br /> PRORATION a a <br /> PLUS <br /> F PENALTY ( O r <br /> .OTHER <br /> F OTHER d <br /> .3 Mailed Deliv ed y <br /> permit No. sua ce Dale 5201 /F <br /> ' Received by <br /> Dat Receipt No. 't601 ErHAZELTON AVE.,P.O.Box 20- STO TON.C <br /> pppLICANT=RETURN ALL COPIES TO: <br /> ENVIRONMENTAL HEALTHPERMITISERVICES -.� _ <br /> I.. <br />