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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable;Revocaple,,`and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> .� LIQUID WASTE l <br /> Application is by matte t carry onpuslne�ss_in t jurisdictional area oft an aquinLocal Healt District <br /> OF Business Name (DBA) �1 ;L Address Q <br /> z Owner Address <br /> J,Firm Partners, Addresses and Telepho a Number <br /> CL <br /> Business Telephone No. • -•�� Emergency Telephone.No.— <br /> Contractor Licence No. { <br /> L Applicants Name (Print) �. - -0;- Title l-7,. Date j <br /> P <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 1, -, June-30, 19 -` ` = Disposal Sites ...'v = - <br /> Description(Make/Yr., Color) 1 <br /> Serial No. CAL.License No.- CAL. License Renewal No. <br /> Capacity -Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. © PUMPER YARD t } <br /> For July.1,,• _._.JUne 30 19 . .�_ _� ._ .� �_�,__ « �.*- - _ �. <br /> No. of Vehicles Stored 1 <br /> No.of Chemical Toilets Stored <br /> 3. ©-PERCOLATION TEST I rr j <br /> .R.S.'Or R.C.E. NameR.S.or R.C.E. No. <br /> P <br /> Tes cation ---Test Date/Time 4 ` <br /> 4. SANITATION PERMIT <br /> Job Address? ation <br /> Owner �OO <br /> .. - Address❑ SEPTIC NK ❑ CESS } LEACHING FIELD SEEPAGE Pl7`A:;❑;'RACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ; 'bNEW OREPAIR ❑fOTHE�R ' <br /> 5. 0 CHEMICAL TOILETS For July 1, June'30,.19 <br /> Type Construction ~f° - '• ; # disposal Site �. a <br /> No.;of Units gquipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT F July 1, -June 30, 19 e t <br /> r <br /> Operator Name.- -- Where.Certified g <br /> ( <br /> Plant Location _ <br /> A Plant Capacity i ( ( No. Units Served <br /> 7. 11•LAUN15RY-._FGrJUly1T.-,June30;,19 . . . ..wj x --,—. - - --�- - ! <br /> SIZE: ❑ Cess Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq.4Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. I e + <br /> HomoewnarorlicensedageFit'zairgnaturecertitiesthefotlowing:"ico0ifythaYinthe performanceof1heworkfor which thlspermitisissued,Ishall not employ anyperson f <br /> in siich manner as to become subject to workman's compersatioa!aws of California-' i a 'N-*.:.. �'� I <br /> Cgnt. ter's I airing or sub-contracting signature cerci ms she.fo#towiog- "I certify that to the gerfor7nce of VI work for vJhieh this perhlit is issued.I shall <br /> employpersons subject to workman's compensation laws of Gaiifo;n4.' — <br /> a - A 4 F s t <br /> I hereby certify that I have prepared this application that the work will be done in accordance with San Joaquin County I <br /> ordinances, state laws, an les and re !a 'ons of t an Joaq ' Local Health District ( � <br /> I <br /> y- -r <br /> APPLICANT'S SIGNATURE_ X • ! k ; <br /> .. <br /> FOR DEPARTMENT USE ONLY - � ;. ;�"�" � <br /> � t j <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 j <br /> ' - _ REMIT i <br /> BASE EXPLANATION BILLING REMITTANCE $ 1 AMOUNT DUE 'CHECKED <br /> DATE DATE REMITTED- <br /> - _ AMOUNT' <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS �^y <br /> . PENALTY <br /> ,OTHER <br /> n' <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Daid I Mailed <br /> 0 O Delivered. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AV"P <br /> B x 09 -STOCKT ,CSA 95201 v <br /> C/(rf�,`/�� U <br /> - f y <br />