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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. y <br /> APPLICATION <br /> ter. <br /> f erable;Revocable, and Suspendable(For Non-Transf <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE _ ,,,fir{ <br /> Application is hereby made to caUon business in theJurisdictional area of the Sa. JoaquinLocal Heal h District. <br /> y Business Name (DBA) Addre 'RaWOX 1 % <br /> z Owner Address 4 <br /> L3 Firm Partners, Addresses and Telephone Numbers <br /> u <br /> CL Business Telephone No. �in-7 . Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) SIMS Title Datea� <br /> Please check Applicable Category,(1-7)and Till in the Required Information - �$ ,..0 L; <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, ' - June 30, 19=?— .-Disposal Sites -` - <br /> Description(Make/Yr., Colon _ <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address _- <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30. 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. © PERCOLATION TEST w ry <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Tes L cation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location ?9 2�sY <br /> Owner QT Add re <br /> ❑ SEPTIC TANK ❑ CESSPOOL MLEACHING FIELD EEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT 11.TEMPORARY ❑ NEW REPAIR ❑ OTHER .ti Od <br /> S. © CHEMICAL TOILETS For July 1,'-June 30, 19 f <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) € <br /> 6".❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 r <br /> Operator Name t' Where Certified <br /> Plant Location r` <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY "For'July 1, -+June 30, 19 ., <br /> SIZE, ❑ Less'Than 1,000 Sq4 Ft., ❑ M}�ore Than 1,000 Sq. Ft. ` }� <br /> ❑ DRY CLEANING, Chemicals Used/Ph9unt/I+Ao. <br /> C.: R* n <br /> HomfemnmarorlicensefiAgent'ssigriaturecertifiestheiotso.raring:"lcerti€yy that inttle.p@rfnrmanceo€thaworkforwhiehthispermitisissued,t.shallnnf#employ.anyperson. �1j1 <br /> in sued manner as to become subject to workrrran s enmpensat:ort laws e€Cafiinrni:i." . <br /> Contractor's hirintj far sub-contracting cignah+r? cP iites ter. f6ttnvwielrj: "I cciflty!hat;n the peftorrtance of the work for which this.pormst is issued,I shall r � <br /> employ persons subject to workman's compensation lavas of Califofnia." T . r <br /> I hereby certify thatI have prepared this applicatiori and that the work will be done id accordance with San Joaquin County k <br /> ordinances, state laws, an and regu ions of the n Joaq ocal ealth District. f< <br /> APPLICANT'S SIGNATURE X p )y <br /> >• FOR DEPARTMENT USE ONLY <br /> i? Fee Is Due: ❑ ANNUALLY ❑ PER UNIT' a ❑ PER SITE •- ❑ EACH ❑ January 1 &Received By January 31 . ❑ July 1 &Received By July 31 # <br /> r REMIT <br /> BASE -EXPLANATION BILLING REMITTANGE 3: AMOUNT DUE CHECKED <br /> k} <br /> 4. <br /> } i DAVE DATE REMITTED AMOUNT <br /> A. FEE <br /> LESS a 3 +� ! <br /> PRORATION <br /> PLUS a 4 i fs C <br /> f. PENALTY <br /> _ OTHER ' + <br /> { <br /> OTHER <br /> f Wilk, a <br /> Received by ; Date + Receipt No. }�E Permit No. ssua ce Da Mailed Delivered- <br /> APPLICANT—RETURN ALL COPIES TO:W ENVIRONMENTAL HEALTH PERMIT/SERVICES1801 E.HAZE E.,P-O.Box 2009 STOCKTON,CA 95201 <br /> t� <br />