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Applications Will Be Processed When Submitted Properly CompleteBeSure o i <br /> APPLICATION <br /> �" (For Non-Transferable, Revocable a,nd Suspendabie) SEPTAGE <br /> ' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUIQ WASTE <br /> Applicat+on is hereby m e to carry n busines the jur s -ctional area of the San Joaquin Local Health District . <br /> r Business Name (DBA) `- ddress <br /> z Owner Address.- <br /> Firm Partners, Addresses'a d T leph ne Num ers Emergency Telephone No. <br /> a <br /> Business Telephone No. ` <br /> -1 Contractor Licence No. d ate r <br /> l• :: . <br /> Applicants Name(Print) !, Title C <br /> Please check Applicable Category (1-7) and Fill in-the_Required information <br /> 1. ❑, PUMPER VEHICLE,PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For-July-,j,- -'1 Jt ne$0-19� --Disposal Sites. - <br /> Description(Make/Yr., Color) =CA•LT`Cicense Renewal No. <br /> Serial No, CAL. License No. <br /> -Capacity <br /> Gai-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 E}E <br /> 3, © PERCOLATION TEST 'r R.S.or R.C.E. No- � - <br /> R.S.for R.C.E. Name <br /> TestiLocation Test Date/Time <br /> 4, ID SANITATION PERMIT <br /> Job!Address/Locationljj ) <br /> Owrier Ad 3�ess <br /> ❑ SEPTIC TANK ❑ CESSPOO 1` ;LEACHING FIELD~' SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORA♦}Y _, ❑ NEW REPAIR <br /> ❑ OTHER <br /> f. <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> i Disposal.Site <br /> Type Construction t ?" <br /> Ni , Units z Equipment Storage/Cleaning Locations) <br /> 6-0 PACKAGE TREATMENT PLAINT For July 1, -June 30, 19 - <br /> Where Certified <br /> Operator Name [ ) <br /> Pla!Location <br /> No. Units Served <br /> Plant Capacity <br /> 7t� 0 LAUNDRY For July-1j-June 30, 19- <br /> SIZE: 13 Less Than 1,000 Sq:Ft., 11 More Than 1,000 Sq. FL y <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. n <br /> Homeowner orlicabsedBgent'ssignalurQcorz`iesthcfeflcwint�:"iCPtlfy hatl�t heperformanCCoftheworkfotw€tich-thispermitisissued•Ishallnoiemployanypersai <br /> in such frlanner as id bbl;Dhle 5tiNec:to r!urkm1n.,'s ctmipet ssflr,:1 law&t7` ' <br /> �f Contractor's hiring'<or-sub-can;ractiV signattoa cerSTios th^ :oitnwing: "I certify Iiat in the perlariiaance a€the work for whichlhis permit is issued,I shall <br /> employ persons subject 30t�ugftMs 66ri,66a5 ion laws of Call` <br /> - I hereby ce that I have3 prepaed this"appflcation and that the Work will lie 7i one m accordance with San Joaquin County <br /> ordinances°`sta ` la ` dl%ru�les an reg tat' ns the San Joaquin local Health�District. <br /> �. � . <br /> YAPPLICANT'S 51GNAT-L7RE X ` <br /> ' 1 <br /> J FOR DEPARTMENT.USE ONLY <br /> Fee IS Due: ❑_ ANNUALLY ❑ PER:UNIgT El PER SITE ,© EACH- ❑ January 1 &Received ByUanuary 31 July 1 8 ReceivedEMIT 31 <br /> ti ' E BI LING ��` } REMITTANCE $ AMOUNT DUE C!-IECKED <br /> AS 'ry_-r r' DATE • - DATE REMITTED - <br /> t ✓+ _ !1! _Ej <br /> �/ <br /> FEE <br /> LESS I � rV Ar' <br /> PRORATION jj _ 111 <br /> PLUS } <br /> PENALTY <br /> tom.•�.✓'' ! <br /> E OTHER " �- . .. <br /> Date Receipt No. Permu NO. � ` "'�``" Issuan' Date Mailed Delivered. <br /> Received:byAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 164t E.HAZEL P.O.E.,POBox 2049 STOCKTON,CA 95201 <br />