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hen Submitted Properly Completed. Be Sure o Sign e <br /> Applications Will Be Processed W <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE I <br /> Appl plica '�isreby to car n bu 'Hess in the jurisdictional area of the San Joaquin L cal H alto i strict . <br /> (3, dress f <br /> Busine Name (DB f <br /> AdIres�, <br /> a Owne 1Wr <br /> Firm Partners, Addresses and Telephone Numbers <br /> Emergency Telephone No. <br /> I Business Telephone No. - �4�' .a zz <br /> a <br /> Contractor Licence No. Date <br /> L Applicants Name (Print) Title <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) CAL. License Renewal No. <br /> Serial No, <br /> CAL. License No.'" <br /> Capacity, Gal., Weights &Measures No. 4 <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 R.S. or R.C.E. No. <br /> R.S.or R.C.E. Name <br /> T I Location Test Date/Time <br /> 4SANITATION PERMIT <br /> Job Addr s/Location <br /> ss <br /> Owner Address <br /> ❑ SEEPAGE PIT E3 PACKAGE PLANT <br /> EPTIC TANK 11 CESSPOOL LEACHING FIELD <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR 13 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site G1% <br />_ No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, i9 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the perNiTn ance of the work for IlMich this permit is issued,I shalt not employ any person <br /> in such manner as to became sri�liw to vvorkmaff,ccmpensa.ioit ialvs of cafiferrlia" <br /> Contractor's hiring or suh viz cafsg stun 1fe certifies " ""'�= ..1 cert-that in 11c perfslrn;ar�;e ei tiro work for which Yhis permit is issued,I shall <br /> employ parsons sublecl IL). o1lu;,Idn-s cul pansat:6n laws o.Caltfos'Isia." <br /> I hereby certify that I have epared this application and that the work will be-done in accordance with San Joaquin County <br /> ordinances, state laws, r Land ulat' Joa in Local Health District. F <br /> APPLICANTS SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 11 ANNUALLY- ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMIT 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT OUE CHECKED <br /> E DA E REMITTED AMOUNT <br /> FEE a.. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER - <br /> I. <br /> OTHER. <br /> Receipt No. Permit No. Issuance Date Mailed kvereci <br /> Re eived by pate L 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL dOPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />