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<br /> Applications Will Be Processed When Submitted Properly CompleteBeSure o W
<br /> y APPLICATION
<br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGF
<br /> A ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE In i
<br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Healt...,District
<br /> mAddress Business Name {DBA)
<br /> rAddress
<br /> z Owner
<br /> a
<br /> J Firm Partners, Addresses and Telephone Numbers1 Emergency Telephone No.
<br /> IL
<br /> Business Telephone No.
<br /> _j Contractor Licence No. Title �� ,�,� _ Date1-7
<br /> 's "
<br /> , ��— ,
<br /> �
<br /> Applicants Name (Print) (�}
<br /> Please check Applicable Category(1-7)and Fill in the Required information g .r
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> t
<br /> For July 1, June-30,'19 <_ -Disposal Sites
<br /> Description(Make/Yr.,Color) CAL. License Renewal No.
<br /> Serial No. CAL, License 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 R.S. or R.C.E. No.
<br /> R.S. or R:C.E. Name
<br /> Test Location �3 Test Date/Time
<br /> UA
<br /> 4. ❑ SANITATION PERMIT .
<br /> Job Address/LocationQ t
<br /> Owner '
<br /> Address" `
<br /> SEPTIC TANK ❑ CESSPOOL EACHING FIELD ❑ SEEPAGE PIT- vO,PACKAGE�P_"CANT , --_.
<br /> ❑ PERMANENT ❑TEMPORARY ❑ NEW ❑ REPAIR
<br /> ❑ OTWER�
<br /> 5. ❑ CHEMICAL TOILETS For July 1, -Junep0, 19
<br /> Disposal Site
<br /> 4 Type Construction i
<br /> No. of Units Equipment Storage/Cleaning Location(s)
<br /> 1 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 Where Certified
<br /> Operator Name
<br /> l Plant Location
<br /> No. Units Served
<br /> Plant Capacity
<br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 ' –
<br /> ❑ "'
<br /> SIZE: ❑ Less Than 1,000 5q. Ft., More Than 1,000 Sq. Ft.�T__.�.._.,�--
<br /> E]-DRY CLEANING;Chemicals Used7Amdunt/mb.
<br /> "orneowner a;licenamdsgent'salt^rfurecnrrH:esShe'.oltcv�irzl "l certity�ai��lir,theperlormance-01 the work far whOthis permit isissued,Ishalino,emplwlarr,pemon
<br /> S In s11c12 mznfler as to I)2GCnie°.tll.)jtG1 til V•'�;1�;111"i`:(,i:ii'G�I•s5r1t "id1".'S wl�i "n-n.' sowe .
<br /> contractor's hiring or sub-con;ac:isg s:a+aturg cin , t to 1'Jlmvving_a'I certifiy that in We parfornianre of the work for which this permii is: d,i s`:a:i
<br /> employ persons subtect.to workman's compensation laws of Galliantia." `
<br /> __.t
<br /> I: ` I hereby certify that I have prepared this application and-thaYthe work=will be-done in accordance with San Joaquin County
<br /> r ordinances, state laws, and rule and re lation f the Sap Joaquin LAocalY �alth D9-k'�
<br /> APPLICANT'S SIGNATURE X
<br /> S _ i *FORDEPARTMENT USE.ONLY
<br /> fs '
<br /> r #
<br /> 4 Fee IS Due:�❑ ANNUALLY ❑ PER UNIT'"' ❑ PER SITE ,EACH ❑ January 1 & ivied By January 31 ❑ July 1 &ReceiveRdEMITuIY 31
<br /> 1 ! I REMITTANCE
<br /> EXPLANATION BILLING ' - .� C$�.:� AMOUNT DUE CHECKED
<br /> BASE € `pATEi. DATE. , ,REMITT.EDy AMOUNT 1r}
<br /> l,� �..�
<br /> FEE
<br /> �
<br /> LES
<br /> Sti ru� 3�r � f ! Z. j �� �••��u "�: �-� 1�t •*•
<br /> # wl PRORATION, '7
<br /> PLUS
<br /> PENALTY . r, � ` 1 , _+� ~".tea. - •• ,« ..
<br /> OTHER :+
<br /> OTHER J
<br /> x t Date Receipt No. - Permit No. Issuan a Date Mailed deliveredBedewed by
<br /> 1601 E.HAZELTON AVE:,P;0,Box 2009 STOCKTON,CA 95201
<br /> APPLICANT=RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES
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