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-Applications Will Be Processed When Submitted Properly Completed. Be SureTosign tne rapp1+cd►� <br /> APPLICATION I!/l�' A <br /> {//1Uj �J <br /> (For Non-Transferable,Revocable, and Suspendable) - SEPTAGE <br /> 4.NVIRONMENTALHEALTHPERMIT <br /> I LIQUID WASTE <br /> Applicat is hereby made caV1r on bus-, ess I the 4uris tionaA area of <br /> the oaqui ocal Health -,strict <br /> rn Business ame (DBA) <br /> Address <br /> aOwner " <br /> 1 Firm Partners, Addresses and Te phot umbers Emergency Telephone No. <br /> aBusiness Telephone No. <br /> -j Contractor Licence No. Z` Title �� Dates I } <br /> Applicants Name (Print) <br /> Please check Applicable Ca ory (1-7) and Fill in t e Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,-Colar) ' CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Gal.,Weights & Measures No. <br /> Capacity` I <br /> E Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For-July.i, June 30, 19' <br /> No. of Vehicles Stored <br /> i No- of Chemical Toilets-Stored <br /> 3. ❑ PERCOL—ATION TEST R.S. or R.G.E.No. <br /> R.S. or R.C.E. Name >;= -,Test Date/Time <br /> Test Location r .� <br /> Q. SANITATION PERMIT <br /> Job Address/Loc�tio _ <br /> ,Address <br /> Owne <br /> 11 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD Q SEEPAGE PIT 0 PACKAGE PLANT Y <br /> MPORARY ❑ NEW 00'REPAIR 11 OTHER <br /> PERMANENT 0,TEMPORARY <br /> •Y � "';,r �. <br /> 5. 13 CHEMICAL TOILETS'For July 1, -June 30, 19 - (A <br /> Type Construction ~ ~ Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) . <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June:30, 19Where Certified <br /> r Operator Name <br /> . : Plant Location y No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 = <br /> SIZE: 0 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> E] DRY CLEANING, Chemicals Used/Amount/Mo. _ <br /> O lane owa <br /> nera.tleend agent`s sig"ture ersdfles she follevArm.. I certify that In the pertormgRce of thcwork for which this permit is issutd,l sh a}i not empEoy alt7l person <br /> jr,such manner as to become subject to workintarl s compensation laws of CaliforrJi <br /> Contractor's hiring or sA)-ceW-ctirw slgrtaturO cerunpR thR 1090w r4. 1 certify that in thB performance at the work for whichthis permit is issued,i shatl <br /> employ persons subject to workman's Lompecsatiors laws of Calif ornia.' <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, nd rules n regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> .� 4 FOR DEPARTMENT USE ONLY # <br /> Feeds Due: El ANNUALLY ❑ PERUNIT ❑ PER SITE El EACH -' ❑ January 1 &Received By January 31 ❑ yuiy l-&Rec fveR�EMIITuVy 3� <br /> BILLING REMITTANCE - - AMOUNT DUE �' CHECKED - <br /> BASE EXPLANATION DATE DATE REMITTED AMOU <br /> FEE <br /> LESS UI` <br /> �- PRORATION E <br /> PLUS <br /> PENALTY <br /> OTHER <br /> L <br /> OTHER 7 <br /> anc Date 2 Mailed' Delivered <br /> Date Receipt No. a•- Permit No A 95201 <br /> Received by - -- 1601 E.HAZELTON AVE.,P.O.Box 009 S�TOCKTQN <br /> raaY7 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES , Oil �2 <br />