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Applications Will Be Processed When Submitted Properly Completed.tieSure 10;5L911 +++W••rr••—• <br /> APPLICATION <br /> J (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH.PERMIT <br /> LIQUID WASTE <br /> \Applic tion Is hereby made to carry on bysiness in the jurisdictional area of t San Jaaqufn Local Health District �� } <br /> +n <br /> Address <br /> Business Name (DBA) <br /> Address _ + <br /> aOwner t <br /> Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> $ Business Telephone No. - <br /> Contractor Licence No. _ Title _Date <br /> �Applicants Name (Print) <br /> Please check Applicable Category (1-7)and lB,in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) o <br /> 'For July 1, June 30, 19 = Disposal Sites A <br /> Description(Make/Yr.,Color) Y CAL. License Renewal No. t <br /> Serial No, CAL. License No. <br /> Capacity Gal.,Weights & Measures No. ' <br /> 4 - <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD y <br /> For July 1, June 30, 19 I <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.Date/Time <br /> f Test Location , �,N e <br /> s 4. ❑ SANITATION PER] <br /> I <br /> S <br /> y Job Address/Location '5 Address <br /> 'u1S ❑ PACKAGE PLANT <br /> g Ow er _ - �- <br /> 1 SEPTIC TANK CESSPOOL `4 LEACHii�IG FIELD SEEPAGE PIT'. <br /> V rREPAIR <br /> 'El OTHER <br /> I PERMANENT ❑ TEMPORARY ❑ NEW a <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction - - Disposal Site <br /> Equipment Storage/Cleaning Location(s) <br /> No. of Units r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> x <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity N <br /> 7. ❑ LAUNDRY For,July l,�-June 30,.19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000'SglFt. <br /> 11DAY CLEANING,Chemicals Used/Amount/Mo. <br /> r` 4 ene " <br /> Home ownw oriloonded ogant's signature certrfies the fol��'1 CenF Vy(list in thepertarmattce of the work iory h3ch this permit is issued,f shalt not employ any person <br /> In such mamor tis to b'kcomi gubject,ty workmari'S cnitlpelisarion laws of California ' <br /> Canovator'n hiring w cub-contracting cignu .e.xertifios ih& following: •'t certify that is t:to performance of the work fofVr th's emit i i su I sliali <br /> amploy persons subject10 workman's mpensaflvzuils-dt�yt` S �� ��' <br /> P hereby certify that I ha repared this ap,A,ft*'and that the wor wi a clone in accordance with an o quln un <br /> Ordinances, state Pawsd and reguia ' ns of the Joaq o al He Ith District. € <br /> r <br /> APPLICANT'S SIGNATURE <br /> 0`felT v� <br /> ti <br /> + FOR DEPARTMENT USE ONLY <br /> Fee is Due: El ANNUALLY �❑ PER UNIT PER SITE. EA ❑ January 1�&Received By January 31 ❑ July 1 &Received By July'31 <br /> REMIT <br /> BILLING REMITTANCE _ $ 1 AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE .DATE REMITTED OUNT <br /> FEE . <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY . <br /> OTHER ,r <br /> OTHER c. l <br /> . 7�- <br /> - 7 .�... Delivered <br /> e mit No, ' Issu nce- ate Mailed <br /> Received by Date Receipt No Y <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2049 STOCNTON,CA 95201 <br /> f <br />