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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.y„ <br /> APPLICATION - w <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> .. - .. ENVIRONMENTAL HEALTH-PERMIT <br /> L <br /> LIQUID WASTE <br /> Appl ication is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District . <br /> Business Name (DBA)��4 � �`S'7F�C�'��g +Address -S72 fir++ <br /> z Owner Address , <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. r- Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information r r. {•. i' <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> 6 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No., CAL. License Renewal No. <br /> Capacity GaL,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 <br /> 3. ❑ PERCOLATION TEST.- <br /> R.S.or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. 9SANITATION PERMIT / <br /> Job Address/Location ` _57— <br /> Owner <br /> 7 aOwner F45_Y47L OF BA,yGWeAS Address E4 pegAaa - <br /> 57 <br /> ❑ SEPTIC TANK ❑.,CESSPOOL ❑ LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANTTp '� <br /> E] PERMANENT 0 TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT FOF July 1, -June 30, 19 <br /> Operator.Name Where Certified <br /> Plant Location <br /> Plant Capacity ` t " No. Units Served <br /> 7..0 LAUNDRY For'July 1, —June 30, 19 `{ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq..Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. e <br /> #14ome owner or licensed agent's "I rartifuthat in the performanceot thework for which this permit is issued,l shall rtof employ any person <br /> in such manner as to become subfact to workrnn;:'s cor,y isation iPLvs ni%Caiifow;a.' <br /> Contractor's htw',rg or scab-contracting si;,nature cert:f;es ttfioiiowing: '-1 certify that in the performance of the work for which this permit is issued.I shall <br /> employ persons-s,c bjeci to workman's compensation laws of California." <br /> rt I hereby certify that I have prepared this ap`plica 'a <br /> hat the work will be done in accordance with San Joaquin County r <br /> ordinances, state laws, and rules and re ulatio of the San oaquin Local Health District. } <br /> APPLICANT'S SIGNATURE X {i <br /> - r- - - - - I <br /> F E <br /> .R FOR DEPARTMENT USE ONLY 4 <br /> Fee IS Due: ❑-iANNUALLY ❑ PER.UNIT, ❑'PER SITE ❑ EACH ❑ January t &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ ; REMIT <br /> BASE EXPLANATION DATE .DATE RMIAMOUNT DUE CHECKED <br /> : - REMITTED AMOUNT <br /> PW <br /> FEE I ,'T�-1` <br /> LESSi- <br /> '.PRORATION r t <br /> PLUS r <br /> .. PENALTY <br /> i <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. I suance Uate Mailed Delivered <br /> APPLICANT—RETURN ALL-COPIES TO: --ENVIRONMENTAL HEALTH PERMIT/SERVICES 1661 E:HAZELTON AVE.,P.O.Box 2909 STOCKTON,CA 95201 <br /> 3 <br />