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Applications Will Be Processed When Submitted Properly o ; <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ' LIQUID WASTE' <br /> F. <br /> Application is hereby made to carry on busi essin the jurisdictional area of the,San Joaquin Local Health District 4 <br /> 10 <br /> Address <br /> y Business Name (DBA) • <br /> F Address „ : a;, <br /> zz Owner- — . 1 . <br /> Firm Partners, Addresses and Telephone e� Emergency Telephone No. v y <br /> aBusiness Telephone No. �S �..3 <br /> Contractor Licence No. 6 a. Date— wg � <br /> �iWi� <br /> A Title <br /> L Applicants Name (Print)Please check Applicable Category (1-7)anthe Requir d Information ,_ <br /> C 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, i9 °^ - - Disposal Sites - s <br /> Description(Make/Yr., Color) ` CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Gal.,Weights& Measures No. <br /> Capacity - + f <br /> Equipment Parking Address - w <br /> 2. ❑ PUMPER YARD <br /> I For July 1, June 30, 19 a <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored 6 <br /> 3. ❑ PERCOLATION TEST !k R.S. or R.G.E.No. <br /> R.S.or R.C.E. Name Test Date/Time ' <br /> i <br /> Test Location _ tw _ <br /> 4. A SANITATION PERMIT ' L ' <br /> Job Addres Location1. <br /> + + " <br /> -776/4� <br /> Address r <br /> Owner <br /> ''El PACKAGE PLANT. <br /> 13 SEPTIC TANK ❑ CESSPOOL JI�I LEACHING FIELD SEEPAGE PITS ❑ OTHER <br /> ❑ PERMANENT C1 TEMPORARY C3 NEW REPAIR t'., <br /> 5. ❑ CHEMICAL TOILETS For July i, -June 30, 19 y` <br /> Type Construction } = Disposal Site <br /> i f = -Equipment Storage/Cleaning Location(s). <br /> No. of Units _ .».�.. <br /> 6. ❑ PACKAGE TREATMENT PLANTT For July 1 June 30,Y19 Where Certified <br /> I <br /> Operator EName. <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 4 {� <br /> 7. ❑ LAUNDRY For July 1, -,June 30, 19 - v <br /> SIZE: ❑ Less Than 1,000 5q. Ft., ❑ More Than 1,000 Sq. Ft. 's <br /> T <br /> ❑ DRY CLEANING, Chemicals Used/AmounUMo. <br /> po„iLownerar EANING;censed hemi Chemicals <br /> U ed/A nount9ticsthef�iawirtg,lcerlity#ha#in#hepertormanceoitheworkforwhichttli5perrnitisisseied,ishal;natnT?Iagaaype r" l <br /> in such manner as to hecn ne subject to worn:Ian's cumpeme Boll 13W8 of Gallfnrm' _ `— ti <br /> conuaetor s hiring or sub-contracti,19 signature carilgias she^feilovrdng: "3 certify that is the per#�rmance of th^ovork for w,",ic!1'Ills 3�rnliti is iss e .I shal4 <br /> empiay persons subject to workma+i s 6mPelsatioa laws of Califnrilia , 4 <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, and rules and regulations o e San Joa Local Health District <br /> APPLICANT'S SIGNATURE X a- "t. ^'• s ,r <br /> s FOR DEPARTMENT USE ONLY j <br /> ❑ Januar 1 &Received By <br /> January 31 ❑ jury 1 &:Received By July 31 <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT-,. ❑"PER SITES ❑ EACH ti Y REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION .DATE. DATE REMITTED. AMOUNT <br /> F E E'er <br /> LESS <br /> PRORATION <br /> PLUS e <br /> PENALTY ,,, <br /> OTHER n <br /> OTHER /QJ <br /> .. — I Su�� e �d Delivered. <br /> Date Receipt No. ermit No. ,, <br /> Receivetl by 1601 E.HAZELTON AVE:,P.O.80=2009 STOGKTON,CA 95201- <br /> APPLICANT--RETURN ALL COPIES To: —ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> t � --- <br /> r <br />