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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transleibble,`ReYnCable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE a <br /> f r Application '�eqr made ar,y,Q1- kyk�iness in the,jurisdictional area of the San Joaquin Local Health District <br /> Business N (DBA) <br /> Address j <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numb rs k .�,.. ;•. �< v <br /> a Emergency Telepfione No. <br /> 0. Business Telephone No. _.. <br /> � Contractor Licence No. t <br /> L Applicants Name (Print) w- _ Title <br /> Dae h <br /> Please check Applicable Category (1-7)and Pill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) U 1 <br /> I For July 1,' - June 30, 19 -- Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. ° CAL. License Renewal No. <br /> Capacity _ Gal.,Weights &Measures No. <br /> Equipment.Parking Address <br /> ( 2. ❑ PL MPER YARD <br /> i For July 1, June 30, 19 <br /> No.'.of Vehicles Stored <br /> No. of Ohemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> r <br /> R.S. o <br /> r R.C.E. Name R.S. or-R.C.E.No. r �_ <br /> Test Location Test Date/Time l <br /> 4.C9 ANITATION PERMIT <br /> Job Address/Location 7 2 <br /> Owner # Address <br /> 11SEPTIC TANK-0CESSPOOL--- PE�k'EACHING-FIEL-D—A"'EEP_AGErP1T----O-PACKAGE,P_LANTI vr/ <br /> rP�E�R � <br /> MANENT ❑ TEMPORARY ❑ NEW R-EPAIR j`,A0 OTHER - <br /> VV { rA► �Y' 1 <br /> j 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> i Type Construction ' r•_4 Disposal Site <br /> No'of Units ;" Equipment Storage/Cleaning Location(s) <br /> 6. El PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Y/ } Where Certified r <br /> Operator Name <br /> Plant Locationt Y -- <br /> F Plant.Capacity No. Units Served - <br /> 7. ❑ LAUNDRY For July.1,--'June 30, 19Y <br /> I SIZE: ❑ Less Than 1,000 SJ Ft., ❑ More Than 1,000 Sq. Ft. <br /> a <br /> ❑ DRY(tLEANING, Chemicals Used/Amount/Mo. _ <br /> Homeowneror licensed agent'sstgrawre mrt3fleethe faflowing:1t t:ertifv that in theperformance of ifn work for Which this perflit.is.kssued,t draft not employ any person <br /> in'such manner as 10 becomo subject to workman's compensation taxs A`I'aitfo>-nia.' I } <br /> i Contractor's hiring or, sub-con)raoling signature eertifias tht l lotloWng: "l c rtify that fA the perfotmance ofttttt work for which thisispermitt s issued;I shall <br /> employ persons subject to workman s cumpwlsation laws of Catlforni ." IC <br /> q � <br /> 1 hereby-certify that!I have prepay t is application and that tcthe work will-be do'ne-inxaccordan ce Viith San JoaLin-County <br /> r ordinances, state laws, and rule an egulati s of the an Joaquin Local Health District. <br /> 'APPLICANT'S SIGNATURE X - <br /> k — <br /> _ FOR DEPARTMENT USE ONLY <br /> ' Fee Is Due: 11 ANNUALLY ❑ PER'UNIT' ❑ PER SITE El EACH ❑ January 1 &.Received ByJanuary 3 ❑ July 1 &Received By July 31 <br /> REMIT <br /> k BILLING REMITTANCE ' $ "'AMOLL)1VT DUE CHECKED <br /> ,► <br /> Y BASE EXPLANATION DATE DATE •REMITTED AMOUNT <br /> +- 00 <br /> FEE 1 r <br /> LESS , <br /> PRORATION ' <br /> PLUS <br /> PENALTY _ <br /> y i <br /> OTHER - '�,I .. � .. �.r` �-•5... <br /> OTHER l <br /> Received by Date Receipt No. Permit No. Issu nce Date = Mailed Delivered <br /> APPLICANT—"RETURN ALL COPIES TO: ENVIRONMENTACHEALTH PERMIT/SERVICES` 1501'E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />