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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.
<br /> APPLICATION
<br /> (For Non-Transferable, Revocable,°and Suspendable) SEPTAGF
<br /> ENVIRONMENTAL HEALTH-PERMIT
<br /> LIQUID WASTE-,•
<br /> Applica 'on is hereby de to carryon bu lness in.the jurisdictional area of th��3S-an Joaquin Local Health Di trict f ,e, ,
<br /> N Busines ame (DBA ° Ad -N 0;_►.?_ ��� C t
<br /> aOwner wo Address
<br /> Firm Partners, Addresses and Tele h ne Numbers
<br /> aBusiness Telephone No. /OEmergency Telephone No.
<br /> Contractor Licence No. Z; L ° ' �
<br /> L Applicants Name (Print) _ Title.--4e. A
<br /> Please check.App�icablef `gory•(!:�1'7)and Fill'I the Required Information k;t16, ,d„+ rl l }
<br /> 1. ❑'PUMPEWVEHICLE'-PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> 01)
<br /> ;:
<br /> For July 1,�-- ¢� Ju'ne,30,19S- ^ - :-.:=: =<.' Disposal Sites
<br /> Description(Make/Yr.„Color) _
<br /> Serial tVo: '' `�' � �-` CAL. License No. CAL. License Renewal No. ,
<br /> Capacity Gal.,.Weights &-Measures No. i
<br /> Equipment Parking Address ?
<br /> 2. ❑ PUMPER YARD
<br /> For July
<br /> No. of Vehicles Stored I '�
<br /> No, of Chemical Toilets Stored � I
<br /> 3. ❑ PERCOLATION TEST
<br /> R.S. or R.C.E. Name R.S. or R.C.E. No.
<br /> Test Location Test Da—te7Tim`e'
<br /> 4. D ANITATION PERMIT
<br /> Job Add r s/Loc tion • 2 4 K
<br /> O,,wnn r Address
<br /> .99 SEPTIC TAN ❑ CESSPOOL EACHING FIELD U EEPAGE PIT ,❑ PACKAGE PLANT
<br /> R�IPERMANENT Q TEMPORARY a ❑:NEW (] REPAIR ❑ OTHER
<br /> r
<br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 S
<br /> Type Construction{ Disposal Site
<br /> iA
<br /> No. of Units Equipment Storage/Cleaning Locations) °
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 f r
<br /> Operator Name-- -- _ .Where Certified
<br /> Plant Location 1
<br /> Plant Capacity { y a No. Units Served
<br /> 7.-13 LAUNDRY For July 1, -June 30,•19 I
<br /> -SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. #
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.
<br /> Homsownererlicensed agent's.'fgP.at'lr0asrflfies thefoRowing:"IcertifythatinthererformawoftheWorkforwhichthispermitisIssued,Ishallnots ploy any person
<br /> in such manner as-to becorne subject to workajan',cor.Fensa'•ton laws of Cafiforn{a,
<br /> Contractor's hiring or n.1 contracting sigrntGic eir"t 05 the toltowing.- 1 certify chat in tha performance of the work for which this per is i'ssrle�I shat!
<br /> employ persons subject to u°orkman's corilpensozioi:I 'rvs of Catifo nia" I u
<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, td rules and re atio of the San Joaquin Local Health District.
<br /> APPLICANT'S SIGNATURE., i
<br /> FOR.DEPARTMENT.USE ONLY . July
<br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑'EACH ❑ Januar 1 &Received BJanuar 31 1 &Received B Ju! 31 Y Y Y Y Y �
<br /> REMIT
<br /> ` BILLING REMITTANCE , ...$ "`
<br /> BASE EXPLANATION ; I AMOUNT DUE CHECKED r
<br /> - —..--i. - DATE- - !, -.DATE f REMITTED
<br /> - - AMOUNT
<br /> FEE . -�. .,
<br /> LESS A r ^! e? U
<br /> PRORATION ' - - • .. -� - e�.., -
<br /> -fir
<br /> i -
<br /> PLUS
<br /> -- PENALTY- - .....�. 1-- { - '�`'.ij t� Q- v2t ' ' r -i- yew rf'
<br /> OTHER ,s., V -.•iT '' -S,ri tr'�' -�.*,. - *'.f`i
<br /> OTHER €
<br /> a
<br /> V
<br /> Received by Date Receipt No. feemil No. Issuancif Date Mailed Delivered
<br /> APPLICANT—RETURl!,ALL-COPIES,TO;�,,,�,ENVIRONMENT,AL-HEALTH PERMIT/SERVICES-�•* --�.-••1601•E.-HAZEL-TON•AVE. P.O.�ox 2009 STOCKTONN,CA 95�201n
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