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j Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> 4 (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL. HEALTH PERMIT <br /> LIQUID WASTE ' <br /> Application i e made to o u ' ess in the jurisdictional area of the San Joaquin Lo ealth District r <br /> k N Business Na a DBA) m - =Address � �� <br /> i Owner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> Q. Emergency Telephone No. <br /> CL Business Telephone No. <br /> } Contractor Licence No. <br /> Applicants Name (Print) Y Tltle _ - Date 1 <br /> _ _ <br /> Please check Applicable Category(1-7)and FIII in the Required Information. , ,� .;� - r . -, <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> ForrJuly 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. ❑ PUMPER YARD; <br /> 'For July 1, June 30, 19 '- %l ` <br /> No. of Vehicles Stored _ <br /> No. of Chemical Toilets Stored <br /> 3. ❑-PERCOLATION TEST <br /> R.S. or,R.C.E.-No. <br /> R.S..ar R.C.E. Name _ ... . <br /> Test Location- Test Date/Time <br /> 4.p6-SANITATION PERMIT <br /> Job Addr s/Location 4 <br /> Owner <br /> Address XX <br /> + ...� <br /> -❑ SEPTIC TANK ❑ CESSPOOL ACHING FIELD OSZEEPAGE PIT ❑ PACKA PLANT <br /> ERMANENT ❑ TEMPORARY 13NEW ., REPAIR E] OTHER <br /> 5. CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction - Disposal Site J <br /> No. of Units Equipme4Storage/Cleaning Location(s) <br /> I - - - <br /> 6. ElPACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name- --� — Where Certified <br /> ; <br /> Plant Location <br /> Plant Capacity ' 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--' <br /> Home o%n ner or licensed agent's sfgnatwa cerNtiesthe folldwinI certify that in the performance of the work lortvhich this permit is issued,l shall not em ploy any person <br /> in such manner as to became subject to workman'-s campersafion faivs at Caiitarni,: ' 1 . 3 <br /> Contractors hiring or sut,-coritracting aignetum carnes tho faflo ina. i certify that in the performance ct the work far which this.psrmit is issued,l shall <br /> `employ persons subject to workman's compensation laws of Cal iloI <br /> I hereby certify that I'have prepared thii app kation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r nd re lotion bf the San Joaquin Local Health Dislr.i t. <br /> r . <br /> APPLICANT'S SIGNATURE X <br /> r ¢1 �� � � _ �d" 1511 <br /> jT <br /> FOR-DEPARTMENT.USE ONLY­ <br /> Fee <br /> _. 4 <br /> Fee Is Due: t] ANNUALLY ❑ PER UNIT ElPER SITE ❑ EACH ❑ January <br /> 1 &Received By January 31 ❑'July 1 S Received By July 31 <br /> REMIT <br /> 1 - F BILLING REMITTANCE $- AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATEREMITTEDr� .AMOUNT <br /> � a <br /> FEE �' C <br /> i <br /> LESS <br /> PRORATION <br /> ✓, <br /> PLUS S!/ <br /> —PENALTY <br /> OTHERS <br /> l- <br /> OTHER <br /> j Received by ! Date Receipt No. Permit No. <br /> Dim.�w . Maired Delivered <br /> - 1601 E.HAZELTON AVE.,P.O.Box 20D9 STOGKTDN;CA 95201 <br /> APPLICANT-RETURN ALL COPIES TO:"'ENVIRONMENTAL HEALTH PERMIT/SERVICES ' <br />