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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.
<br /> r APPLICATION
<br /> (For Non-Transferable, Revocable,and Suspendable)
<br /> SEP7AGE
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE
<br /> Application i ereby mad Eo carry business in th ' nsdictional area of the S Joa uin Local Health Distric
<br /> ,„Business Name BA) _ Address -µ�
<br /> I- Owner Address
<br /> Firm Partners, Addresses and Telephone Numbers
<br /> aBusiness Telephone No: t��.b.;5,. Emergency Telephone No. _ T
<br /> Contractor Licence No. .. �2—
<br /> L Applicants Name (Print)- -- - Title <Date
<br /> Please:check"Applicable Catego ; ) and Fill in the Req red Information
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> For July 1, ` June 30,-19 Disposal Sites
<br /> Desc'riptio'n(Make/Yr.,-Color)
<br /> Serial No--'� I CAL. License No. CAL. License Renewal No.
<br /> t,. CapacityAdGall,Weights & Measures No.
<br /> Equipment Parking d ess
<br /> 2. ❑. PUMPER YARD
<br /> .r For JMuly,,1 June.30,'19';"
<br /> {.
<br /> t+I0, of Vehicles Stored' '
<br /> No. TC;hernicail Toilets Stored f
<br /> 3. ❑ PERCOLATION TEST j
<br /> R.S.or R.C.E. Name Y ( R.S. or,R.C.E. No.
<br /> Test L tion ( Test Date/Time-
<br /> t ,
<br /> 4. LJ SANITATION PERMIT
<br /> Job Addre s/Location Ste_
<br /> Owner t Address
<br /> i .
<br /> C1 SEPTIC TANK ,❑;CESSPOOL LEACHING FIELD SEEPAGE PIT El PACKAGE PLANT
<br /> PERMANENT ❑ TEMPORARY { ❑ NEW &FIEPAIR ❑ OTHER
<br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 p)
<br /> { Type Construction t Disposal Site
<br /> No. of Units Equipment Storage/Cleaning Location(s)
<br /> 6. ❑ PACKAGE TREATMENT PLANT TFor July 1, -June 30, 19
<br /> Operator Name `� s Where Certified
<br /> t Plant Location
<br /> C Plant Capacity ' No. Units Served
<br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 �
<br /> L SIZE: ❑ Less Than 1,000,Sq...F_t.,_,,, -More Than 1.,000 Sq. Ft.,. �-
<br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. w•
<br /> ifatee ownevorlicenaed agent's signature certifies the following.-"I certify that 1n the p erfofm 6nce of tt a work for which this permit 3 issued,,I S14211 fret emptoy any pemrt
<br /> in such manner as to become subject to workman's colni;ersafian lards of C-Afor o;- ' i
<br /> Contractor's hiring or sub-colitmctirr� signs t;ue certifies *t r,-fottowing; i CC 7i;,";�;i;n ih9 NerfOSfnat7 C"pf the work far which rer nit rs i55�ed,i Shall
<br /> emplO� n^rsons sucject to xol'<;,sail's cart ie:satiur iaxs at C :xi;
<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, and ,rules and,regulations of the San Joaquin Local Health District, '
<br /> APPLICANT'S SIGNATURE � `-""�1�
<br /> I ��� .y..-� �..y N.•]'r•'b1'.,,Aj"�^ =1-kj�„f,�' �".'^. F Mw! .. ��'.��. � � / �4-'1�~^'
<br /> FOR DEPARTMENT USE ONLYry
<br /> Fee Is Due: ❑ ANNUALLY [ PER UNIT ❑ PER'SITE .J] EACH { ❑ 9anuary.18 Received By January 31st :❑ Suly 1 &Received 8y July 31
<br /> r - , u' REMIT
<br /> xBILLING REMITTANCE r $ ^ r
<br /> RASEEXPLANATIONJ4' '4� „ AMOUNT DUE CHECKED
<br /> _DATE ; DATE REMITTED: AMOUNT
<br /> FEE
<br /> LESS
<br /> PRORATION
<br /> PLUS e
<br /> PENALTY
<br /> OTHER
<br /> OTHER t,. �- '�:M.:�• 4:.' .,
<br /> Received by ? Date Receipt No PErmil No. I uance ate-- Mailed. Delivered. -
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201
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