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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ,
<br /> APPLICATION
<br /> (For Non-Transferable,Revocable,'and Suspendable) SEPTAGE `
<br /> ENVIRONMENTAL HEALTH;PERMIT
<br /> LIQUID"WASTE ti
<br /> 4
<br /> Application is hereby made to carry on business in he j isdictional area of the.San Joaquin Local Health District
<br /> .n Business Name (DBA) Address _10,
<br /> z Owner
<br /> Address
<br /> - - -
<br /> J Firm Partners, Addresses and Telephone Numbers
<br /> aBusiness Telephone No. !Z6 o 7 Emergency Telephone No..
<br /> Contractor Licence No. MF, F =a�
<br /> Applicants Name (Print) - Title Date; �" '
<br /> Please check Applicable Category.(1-7)and-Fill in the Required Into mation
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> For July-1,-.-:- - June 30, 19"' Disposal Sites--
<br /> Description
<br /> ites Description(Make/Yr., Color)
<br /> Serial No. CAL. License No., CAL. License Renewal No. -
<br /> Capacity 'Gal:,Weights& Measures No. y
<br /> Equipment Parking Address
<br /> 2. ❑ PUMPER YARD
<br /> For July 1, June 30, 19No. of Vehicles Stored.
<br /> : Ir
<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 * , r
<br /> ,Test Location Test Date/Time
<br /> 4. 9 SANITATION PERMIT
<br /> Job Address/Location e
<br /> Owner Address
<br /> 11 SEPTIC TANK, ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT
<br /> x*
<br /> ❑ PERMANENT 13 TEMPORARY _❑ NEW ® RE ❑ OTHER
<br /> r
<br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19
<br /> Type Construction Disposal Site ( J
<br /> �No, of Units I E. Equipment Storage/Cleaning Location(s)
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 s i
<br /> Operator Name `i. 'Where Certified i
<br /> Plant Location }
<br /> r
<br /> Plant Capacity No. Units Served ;
<br /> 7. 0'.LAUNDRY For July 1, -June 30,.19 --
<br /> SIZE: ❑ Less Than 1,000 Sq,,Ft,, ❑ More Than 1,000 Sq. Ft. ` -
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.
<br /> Hamaownerort;censedagent's signature certifiesthefollowing:"l certi[yt11a11ntheper!crmartceof thework forwhich This permit is issued,l shall not employ any person.
<br /> in such manner alto become subiect laws of C lifrrr:ix" t "
<br /> Contractor's hiring or sub-eont'ractinn signjjtnrA eertitirs thr� fo;lovs:rte: 1 CErtity that in t3r8 pe;: rT 2nCe o;the titiei k for which th15 permit is issued,l Shall
<br /> . empFoy Gersalts subject to>,rorktna�s ctrmpeltsaiinn I�t+us o1"Calitornia." � Y
<br /> ' I hiereby 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 rul and regulations of the an Joaquin Lo ealth istri0t.
<br /> APPLICANT'S SIGNATURE X »
<br /> FOR DEPARTMENT USE ONLYy
<br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Received By July
<br /> El
<br /> , . REMIT
<br /> t I BILLING REMITTANCE $ AMOUNT DUE CHECKED
<br /> BASE EXPLANATION ' ��.DATE__ .p,,,,..,DATE ,.,.,AREMITTED�. ...�...,......-, ..� �' AMOUNT -
<br /> -
<br /> FEELESS
<br /> PRORATION - I - �'0.. �'l.. 'i - . t „]._ ° +i► _
<br /> PWS
<br /> PENALTY ;
<br /> OTHER H -
<br /> OTHER
<br /> 36
<br /> Received by #: Date Receipt No. Permit No. 1 suance Date 1 Mailed Delivered -}
<br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL-HEALTH PERMIT/SERVICES 1601 N E.HAZELTOAVE,P.O.Boz 2009 STOCKTON,CA 95201 -
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