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F- <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure o Sign e <br /> APPLICATION t • - =' <br /> (For Non-Transferable, Revocable,and Suspendable) i , SEPTAGE <br /> 5 - r ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applis cation hereby made to carry on business in the'jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) <br /> e •� Address Q <br /> i Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> MBusiness Telephone No. . Emergency Telephone No. <br /> a Contractor Licence No. <br /> � <br /> Applicants Name (Print) Title Date <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, 19Disposal Sites <br /> Description(Make/Yr.,Color) <br /> Serial No.— CAL. License No. CAL. License Renewal No. <br /> � 1 <br /> Capacity Gal., Weights & Measures No. l <br /> Equipment Parking Address <br /> 2. ❑ 'PUMPER YARD f t <br /> For July 1, June 30, 19'r <br /> No.of Vehicles Stored <br /> _ t <br /> No. of Chemical Toilets Storedt <br /> 3. ❑ PERCOLATION TEST i A x, "T € <br /> R.S.or R.C.E. No. € "� <br /> R.S. or R.C.E.Name <br /> r - _ Test Date/Time _ <br /> Test Location . ,� c <br /> 4. SANITATION PERMIT tf I �' q <br /> �S. .. 1 �.»3f�G S !�� -r fly t <br /> Job Address/Location <br /> Owner V Address <br /> SEPTIC TANK C3 'CESSPOO"$N <br /> LEACHING FIELD 61 SEEPAGE PIT' ❑;PACKAGE PLANT _ <br /> PERMANENT .❑ TEMPORARY EW ❑ REPAIR ❑ OTHER `S t ` <br /> 41 <br /> 5. ❑ CHEMICAL:TOILETS For July 1, -June 30, 19 V <br /> Type Construction' Disposal.Site.•. -- -- <br /> No. of Units Equipment=Storage/Cleaning Location(s) I <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name r <br /> Plant Location <br /> Plant Capacity f No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 t _ $-rte <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DIII�NIN%Cheer�licais Used/Amount/Mo. : f <br /> ror s agent a signature certifies the following:"I Certify that in the p6l"Mrmanceofthe work for which this Permit.isissued,lshall not employ any persor. <br /> t-•in,Sucft manner as to become subject to wo;k, asi s Camtlensatiilrl lq% Rf f;aOcIrnia <br /> Contractor's hiring or buts corttraeting jOnpturis"e-cettsf e: t56 "i'eltovvinn: cwti`y th Zt in the pertornlasl e wthe I otF fcr 4vhi,h this permit 1s issued,I sMl <br /> employ persons si bjectio tuorhnlali s�e n,,s;sa;soll I cf Cc!Ilia.' <br /> •. - - � -•,.,Ham.• . ,�, �. � � � . , ,. ..P. <br /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, an ules and regul - ns of the Joaquipfocal Health District. <br /> APPLICANT'S SIGNATURE-X <br /> i <br /> :r <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: 1:1 ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH ❑ January 1 &Received By January 31 El July 1 &Received BITuIy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE, DATE REMITTED AMOUNT <br /> 3 ,?: v 41S <br /> FEE s <br /> l ./ <br /> LESS <br /> PRORATION <br /> PLUS �I71 <br /> PENALTY iVf �e>l�iov T� <br /> �g:/' <br /> OTHER c C 7�.4•�f/'� fob G.v 401- (/��O/��f� <br /> OTHER : <br /> A, 49.r y <br /> Received by Date Receipt No. �+:4Permit No: � ' �'t.l suan a Date Mailed Delivered <br /> +- 1601 E.HAZELTO <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES N AVE.,P.O.BON 2009 5O G15201 <br />