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Applications Will Be Processed When Submitted Property Completed.Be SureTo Sign <br /> APPLICATION <br /> (For Non-Transteratsle;'Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEAL-TH,PERMIT ����, <br /> LIQUID WASTE- �p j <br />' Application is hereby made to carry on business in the jurisdictional area o1 the San <br /> again Local i D <br /> Address�& <br /> NBusiness Name (DBA) G- - <br /> a Owner . .Address <br /> ...� ;� ...v.. <br /> S) Firm Partners, Addresses and Telephone Numbers <br />{:. a Business,Telephone No. y Emergency Telephone,No. - <br /> K <br /> b 1~ <br /> A Contractor Licence No. . - _ _ - w "� - -: <br /> ` Q. . _TIt1e ti r Date <br /> Applicants Name (Print) <br /> Please check Applicable category(1,-7)and Ftli.i,n tfie Required Information ^t~'f' <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1; June <br /> 30 19 `" .-Disposal-Sites <br /> --= - <br /> Description(Make/Yr.,Color) - <br /> " License NV- <br /> Capacity <br /> License°Renewal-No.----�=t <br /> Serial No. CAL: r" <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 Lo Ion 41 Test Date/Time <br /> 4. SANITATION PERMIT <br /> 4-1 Job Address/Locatio Z ✓C �� <br /> Owner [,J Dp„/, Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ` ❑ LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ NEW IJ S-ETHER <br /> ' <br /> 11 PERMANENT C] TEMPORARY <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <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 <br /> tt <br /> � � Where Cel'tifieda`, _ , <br /> Operator Name <br /> Plant Location <br /> ND Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., C3 More Than 1,000 Sq.ryF_t. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 4 <br /> Homs owner oriteensedagent's sfgnaturec�utiflesthefosawing:1ceft tti�tinthe'performenceoftheworkforwhichthis pennitlsl5sued,l0alinot employanyperson <br /> in such malmer as to become subject to workman's compensation laws of Ga ifol=nia" lY <br /> contractor's hiring or sub-contracting .signature CettilissTttlB`3glloyring:` I certlty that.fn the performance of the work for which this permit Is i1sued11 shail <br /> employ persons subject to workman's compensation laws of California:"s. `• ' w .,,_, :� .-. Y—!. � <br /> � tt <br /> I hereby-certify That I have prepared this application and that the work will bye done In accordance with San Joaquin County <br /> ordinances,state laws, and rules an egulations_of the San Joaquin Local Health D,istnctNi\, �� _ <br /> / to <br /> APPLICANT'S SIGNATURE'X - `�►'' " „ �`' 9 i <br /> FOR DEPARTMENT USE ONLY <br /> y- <br /> LLY ❑_ 'PER UNIT ❑ PER SITE ` EACH January 1 &Received By January 31 0 July 1 &Received By July 3i <br /> Fee Is Due: 11 ANNUALLY - - - REMIT <br /> BILL'iNG REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE E%PLANATION DATE - DAVE REMITTED AMOUNT <br /> FEE <br /> �+ <br /> LESS _ . <br /> PRORATION <br /> 0 <br /> PLUS <br /> PENALTY - <br /> OTHER J <br /> OTHER <br /> Date Mailed Delivered" <br /> Received by <br /> Date 'Receipt No. ermit No Issuance <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE., Box-2009 - "570Cf�ON�CA 95201 <br />