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iApQlacatfons Will Be Processed When Submitted Properly uOrnpicill o� - <br /> j APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> 10i �, ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE t <br /> Application i �by_made,to r oy�us}gess i the jurisdictional area of the4�n�Joaqusin iocaLlieaifh�Dfc����„--- <br /> f/C� Address <br /> ,F Business Na BA}; � , .. .,. .•�.� iYrr_ , � .. , <br /> Address }`; •- - <br /> a Owner _ a <br /> L Firm Partners,Addresses an Telephone Numbers Emer envy Telephone No. <br /> Business.Telephone No. <br /> _ 9 '''{ <br /> Contractor Licence No. J c Date 0- <br /> z <br /> Title <br /> Applicants Name (Print)` <br /> 1 7 and Fill In the Required Information It -t•.'}r 'I'Y� <br /> Please check Applicable Category( - ) T' <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, &une 30, 19._.;---- - <br /> _.Disposal Sites <br /> Description(Maki .Color) CAL"License No. CAL.'License Renewal No. <br /> Serial No. <br /> 'Capacity Gal.,Weights&Measures No. <br /> _ Equipment Parking Address h - <br /> 2. ❑ PUMPER YARD — <br /> For July 1; Ib une 30, 19 _ <br /> No.of Vehicles Stored <br /> •� No.of Chemical Toilets Stored , <br /> ❑ PERCOLATION TEST <br /> 3. R.S.or R.C.E. No. <br /> R.S.or R.C.E.Name <br /> Test Date/Time <br /> I <br /> _ TeXsSation tf p <br /> 4: ANITATIONPERMIT <br /> Job Address Location ill10 Address <br /> EEPAGE PIT ❑ PACKAGE PLANT <br /> Owner❑ ❑ LEACHING FIELD S <br /> ., SEPTIC TANK ❑ CESSPOOL ❑ NEWREPAIR 13 OTHER <br /> ❑ PERMANENT ❑ TEMPORARY <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June Equipment <br /> 1Dlsposal Site <br /> Type Construction u <br /> No.of Units Storage/Cleaning Location(s) <br /> .. . <br /> g• <br /> 13 PACKAGE TREATMENT PLANT For July 1,-,lune 30, 19 Where Certified <br /> Operator Name ° <br /> �i Plant Location No. Units Served w <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July-1,-June 30, 19 <br /> Than 1,000 Sq. Ft. <br /> ' SIZE: ❑ Less Phan 1,000 Sq"Ft., ; <br /> ❑ DRY CLEANING,Chemicals Used/AmounUMl% i - <br /> natte+eearttfi9ethefoftowtnB' Icertt!YIll the WtormanceofIf+ worktorwhichthispertilisissued,lshall note <br /> mployanyperson <br /> Nonleowneroricensedagent'sslg i r <br /> ni atvro certifies Nle foauNan9 -.1 certify that in the-performance of the ti:ork for tlriticit this Permit is issued,l shall <br /> in such manner as to become subject la workman's compensation taws of Ca iloilll..��, <br /> I ConVeMil hiring ii sub-contracting'.gn, <br /> 41„1,plpy per$ons�ublect to workman's compellsatlon taws of California." <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> reg ions oft San Joaquin Local Health District. <br /> ordinances,state laws,and rul 1 <br /> i w <br /> APPLICANT'S SI <br /> NATURE X <br /> FOR DEPARTMENT,USE ONLY <br /> ❑ January I &Received By-January 31 ❑ July t &Received By July 31 <br /> REMIT <br /> Fee is DU.i❑ ANNUALLY CI PER UNIT PER SITE EACH <br /> AMOUNT DUE CHECKED <br /> i pp11 BILLING REMITTANCE REMITTED AMOUNT <br /> i BASE EXPLANATION DATEDATE <br /> LESS <br /> PRORATION. �r ,) /G 1 <br /> PLUS <br /> PENALTY <br /> _ r <br /> OTHER <br /> OTHER _3� <br /> Millnce Data Mailed Delivered <br /> X Mill <br /> Permit No. $TOCI(TON,CA 9&201 <br /> i b'y <br /> Date Receipt No. 1601 E.HAZIELTON AVE.,P.O.601 2009 <br /> Received <br /> APPLICANT—R£rURN ALL COPIES TO' ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />