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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> �r <br /> For Non-Transferable,Revoeabte,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applica ion Is hereby made to carry on bus• s in th ju'sdictional area of the San Joaquin Local Health District <br /> y Hess Name (DBA) C- Address <br /> zOwnerLEF7. Address UkA <br /> %j Firm Partners,Addresses and elephon Number <br /> CL Business Telephone No. 1 Emergency Telephone No., r <br /> Contractor Licence No. _ <br /> L N me Applicants' (Printy.= Title oat, <br /> Please check Applicable Category(1 T.and Fill In-the Required Information. <br /> I. El PUMPER VEHICLE PERMIT•RE'GISTRATION(FOR EACH VEHICLE) µ <br /> For July 1, June�30, 19 r t Disposal Sites <br /> Description(MakeNr.,Color)--_ <br /> Serial No. I " C " <br /> CAL.License Na.. eGAL.-License Renewal No. <br /> 'Capaa(ty^�—�^^•--+--•- - �Gal.,-Weights-B-Measures�lo:� �' =� J �S,.r:..�� i'1 _ � <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD 1 <br /> ^For�fuly-1;June 30-'h9+- -,.r.•.-.- >�- _._ <br /> No.of Vehicles Stored t r•,r^Vc ' <br /> No.of Chemical Toilets Stored 1 <br /> 3. 0 PERCOLATION TEST <br /> R.S.or R.C.E.NameZZ Te/n, t R.S.or R.C.E.No. { ', <br /> Test'Location f l f Test Date/Time <br /> 4. 0 SANITATION PER VlT.. y ^ ,,! 1 • n �' <br /> Job Addre tion 1 ) <br /> Owner ,I f Address l i <br /> ❑ SEPTIC TANK r ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT 0 PACKAGE PLANT! i <br /> ❑ PERMANENT 1 13 TEMPORARY NEW I EPAIR ❑ OTHER <br /> S. <] CHEMICALTOILETS For July 1,-June 30, 19 1 f <br /> 1 <br /> ^e Construction'_ ( Disposal Site <br /> �f Units f i Equipment Storage/Cleaning Location(s) t = r <br /> 5. ❑ PACKAGE�REATMENT;PLANT For July 1,-June 30, 19 I <br /> Operator Name j 1 Where-`Certified <br /> Plant Location <br /> Plant Capacity No.,Units.Served 1 1 7 <br /> 7. I] LAUNDRY I For July 1,-'June 30 19 -x' �_,.j. ! <br /> SIZE: ❑ Less Than 1,006 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> 0 DRY CLEANING,Chemicals Used/Amount/Mo. I <br /> Rome ownerar acensedag"W3alpnaturoeeitNlestha 1 <br /> in such manner as to ltecome sotyect to workman's corn 0 � t e thatin f3reperformanm of the lvork f ivhleh this petlntt 131ggued,(sf►all not enJ <br /> Comnctor e � wbioexacti pcasattott taws of Ca Itornia:' ployany person <br /> siI algtMtws9 certifisp the lot l <br /> emproy persons sabjea to worWnan'a comWRsation favus of Catifotnia ' certify that in the perlorTlanco of tMe work for witich Ift permit is Issued I Shall � .S <br /> } <br /> I hereby certify 1 have pre ed this apiication and that the work will be done in accordance with San Joaquin County , ti <br /> ordinances, law nd rules d regula ns Of a Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE 1 <br /> { � j <br /> r r � � <br /> FOR DEPARTMENT USE ONLY �. .. <br /> I Fee Is Due: 11ANNUALLY ❑ PERI <br /> (UNIT! ❑ PER SIT9�❑ EACH ❑ January 1&Received By January 31 ❑ July 1&Received By July 31 a <br /> t /+.� BILLING REMITTANCE S 'AMOUNT DUE CHEMKED 1 <br /> IT <br /> BASE EXPLA'NAT1bN <br /> } �+ DATE DATE _,REMITTED <br /> FEE 17' vr;4 x A NT i <br /> LESS <br /> PRORATION } /� <br /> + PLUS <br /> ' PENALTY <br /> OTHER <br /> OTHER <br /> l i <br /> Received by Darn Receipt No. Permat No. - Issuance fate N Mailed Delivered # <br /> �� APPLICANT-RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTO ,P.O.Sox 2008 STOCKTON,CA 95201 <br />