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Applications Will Be Processed When Submitted Properly Complezeo. wesure lu alwit • �•+rr -• <br /> APPLICATION <br /> (For Non-Transferable;ReYocabie;'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-_PERMIT <br /> mm <br /> LIQUID WASTE µ <br /> r <br /> . Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local,Health Districl. <br /> Business Name(DBA) `Address - <br /> a _ Address <br /> a Owner <br /> I: J Firm Partners, Addresses and Telephone Numbers <br /> $ Business;Telephone No. - - c <br /> _Emergency Telephone.No. <br /> ,u <br /> Contractor Licence No. -Title to - <br /> - w� Da <br /> LAPPlicanIs Name�(Ptiri!)F`r `! _ <br /> Please check Applicable Category (1-7)and Fill In the Required Information <br /> 1.;O,PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> ' Disposal Sites= <br /> For July 1, - 'Juhe 30,-19 <br /> Description(Make/Yr., Color) w <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity' ^ -Gal:,:Weights &Measures-No. - -a <br /> Equipment Parking Address — - —{ <br /> 2. ❑ PUMPER YARD <br /> For JI <br /> uly s June 30, 19 <br /> No. of Vehicles Stored - ! .� <br /> No. of Chemical Toilets:Stored I } <br /> 3. ❑ PERCOLATIONTESTi 1 <br /> F ! 'R.S.,or R.C.E. No. <br /> R.S..or R:C.E. Name - ) <br /> Test�Loc ation Test Date/Time 6 <br /> 4. ❑ SANITATION PERMIT \ <br /> Job TAddress/Location <br /> 'Owner Address 4 Q <br /> ❑ SEPTIC TANK ❑ CESSPOOL- ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 17, <br /> 11 PERMANENT ❑ TEMPORARY El NEW C3 REPAIR ❑ OTHER <br /> 5. 1:1 CHEMICAL TOILETS For July 1, -June 30, 19 + <br /> Type Construction- -- r= -Disposal Site t 'I <br /> No.of Units j EquipYnent,Storage/Cleaning Location(s) l <br /> 6. ❑ PACKAGE-TREATMENT PLANT For July 1, -Jurie 30; 19 = iYlt I x <br /> - Where-Certified' <br /> Operator`Name s <br /> Plant Location <br /> Plantt Ca -_ityl r 1 No. Units Served ,fit <br /> J }, <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19s <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than,1.,000 Sq. Ft. , <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t Name''bwnerarlirrrcedl:,e^'.'a SgnzissrAp rtfiesthefollovi;ng:1rertitythWinthe perfermanceofthe work for wNchtNspermit isIssued,fshall not employanyperscn <br /> i,. If]SUCK n73il:IC�dS iti$9;;pr SaLllc'< L �43t -i {`C i�pen52Ji r2'+IS <br /> 1, Contractar's l:lr na or thb Mliowing "I certify tha lit tIFO @rf6flnar:Ge Gf the Work to:which this permit is ISsw?d;1 Shall <br /> - ; -'` BfTi�lOy persons si;b;eet�31`1Jt�.i"yITS COfT)p4r;5:3ilil;I,e�V$3t v3iii�i�EiiiI � ' <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> �* ordinances,.state laws, and rule$.an'd regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X l :� <br /> - •`.f. Ll t R <br /> r, <br /> t FOR DEPARTMENT USE ONLY <br /> Fee Is Due: C3 ANNUALLY ❑ PER UNITI ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July31 <br /> REMIT <br /> I BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> EXPLANATION BASE REMITTED <br /> � - !. 9 DATE 'DATE AMOUNT ' <br /> I' FEE .. <br /> PRORATIONLESS <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER_ <br /> k Date i Receipt No. Permit No. Issuance Date 'Malted , Delivered I <br /> Received by - �„ - E.HA2ELTON AVE.,P-O.Box 2009 STOCKTON,CA 95201 <br /> .- <br /> APPLICANT—RETURN ALL COPIES To; ENVIRONMENTAL ONENTAL HEALTH PERMIT/SERVICES 1601 <br />