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s Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The,Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application ipqrtW made toFgi)Y on ousinq§s in the jurisdictional area of the San Joaquin Lo Health District <br /> OF Business Name (DBA) 57 0 /C 6 1LC Address__1'7..Ct1tr 4Rew— <br /> z OwnerAddress. - - <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. -- - Emergency Telephone No, <br /> Contractor Licence No. <br /> Applicants Name (Print) N •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, 19- - - Disposal Sites <br /> Description(Make/Yr., Color) - l <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,"18 <br /> No. of Vehicles Stored <br /> .r <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�Locn Test Date/Time <br /> 4. (&'SANITATION PERMIT <br /> Job Address/Location <br /> Owner I Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL `, LEACHING FIELD PK SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW R.REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 �- <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Clea Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location 1 ` <br /> Plant Capacity r No. Units Served <br /> 7. ❑ 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. .f t a 1 <br /> Home owner wllt�errfedagepYssiQnslvreoertfflleatfiefoillowhM.-1certify tRatintheperformance offhework for wihkhthispermitisissded.Ishall no!employanyperson <br /> in such manner as to become subject to workttmPi s componsaIinn tales;,I(,aliteriia ' f i <br /> caitraetor's Kirin$ orsub-contracting signature certi'.es the fulieu rub:_°'I.certl ly that in the periormanse of the urork for which this permit is issued,I shall <br /> employ persons subject to workman's cornpensatian laws of CGaMorn=,a. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquino $�3 <br /> ordinances, state laws, and rules regulatio of th San Joaquin Local Health District. $ 9q <br /> I L ' 9'' <br /> APPLICANT'S SIGNATUREX <br /> = FOR DEPARTMENT:"USE O LY <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT E] PER SITE ❑ EACH ❑'January t &Received By January 31 ElJuly 1 &Received By July 31 <br /> r REMIT <br /> BILLING REMITTANCE $ <br /> " BASE �* EXPLANATION DATE - ''DATE - - REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE S <br /> LESS <br /> PRORATION - ~ - <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER , <br /> `� - g . - <br /> Received by Date Receipt No Permit No. Iss4bance We a Mailed Delivered <br /> - APPLICANT—RETURN'ALL-COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON, 95201 <br /> y <br />