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Applicaflons Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> i (For Non-Transferable,'Revocable,and Suspendable) SEPTAGE <br /> w <br /> ENVIRONMENTAL_ HEALTH-PERMIT <br /> i LIQUID WASTE <br /> •r Applicatio ere�py mad�e,t0 c on bus Hess int a jurisdictional area of the-San Joaquin Local ealth District- a <br /> H sI <br /> Business Name (DBA -_ AddresY <br /> �� <br /> aOwner _ A dress <br /> 2 Firm Partners, Addresses and Telephone Numbers <br /> f c Business Telephone No. �� Emergency Telephone No. -� <br /> k.. Contractor Licence No. / <br /> Title Y Da to <br /> { L Applicants Name (Print) ' . n <br /> [ Please check Applicable Category -7) and'Fill in the Required Information,' r t' r'::`• <br /> IE <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Dis - — — l <br /> For July 1, - June 30, 19 �--"�- = Posai Sites � <br /> Description(Make/Yr., Color) r ... . - ► ^' <br /> 4, Serial No. CAL. License No. CAL, License Renewal No. <br /> Capacity` Gal.,Weights & Measures No. <br /> p Equipment Parking Address ; <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19` t <br /> j No. of Vehicles Stored <br /> I � <br /> No. of Chemical Toilets Stored t ,. <br /> 3. ❑ PERCOLATION TEST r '" � E <br /> R.S.or R.C.E.No. <br /> F R.S. or R.C.E.Name - <br /> Test Location Test Date/Time <br /> f 4. SANITATION PERMIT r i <br /> h Job Addre Location <br /> r Owner . rr T ri ' f A dress <br /> .SEPTIC TANK ❑ CESSPOOL LEACH NG FIELD ❑ SEEPAGE PIT El.-PACKAGE PLANT Cit <br /> I PERMANENT ❑ TEMPORARY 4EW ❑ REPAIR ❑ OTHER r <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 : t <br /> Type Construction i Disposal-Site <br /> No. of Units Equipment Storage/Cleaning:Location(s) C <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 _ ^ <br /> Operator,Name Where Certified <br /> I <br /> t Plant Location x, - C <br /> V_ % No. Units Served r <br /> ._-,Plant-Capacity E 4 <br /> y: 7. ❑ LAUNDRY ,For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft <br /> ❑ DRY GLEANING, Chemicals Used/Amount/Mo <br /> Homo ownBrOrlicensedapent'soign-Fturg1 Ir2rfifythatutheporfornlr,-.,ofi14c,II '?,'for whichthi,ppl mit is lrislicd,[shall nrOe`?SFloyany perrIGN"C <br /> In such manner as tn become subject to workman s corlpensation laWS of California"' r <br /> r Contrnctor's hiring or sub-ecntracting.signatwe-Gertifles the-following: "I rertily-that in the performance of t`Ie work tar wikich this uerrrit is is4uesl,I shall <br /> Ij employ persons subject to workman's compensation-imus of California." t. r <br /> hereby certify that 1 have prepared tfiis application and that the work"will-be done in accordance with San Joaquin County <br /> ordinances, state laws, and rul s and regulations of the Sari JoaquinLocal Health District. n <br /> APPLICANT'S SIGNATURE X •- - -; ' <br /> + -i• FOR DEPARTMENTi USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER.UNIT. ❑ PER SITE i ❑ EACH ❑_January 1 &Received By January 31 ❑ July 1 &.Received By July 31 <br /> t• . - VAN <br /> BASE EXPLANATION BILLING REMITTANCE $ s <br /> - AMOUNT DUE <br /> DATE DATE REMITTED AMOUNT <br /> I: FEE l c LESSPRORATSONPLUSPENALTYOTHER <br /> xy. L <br /> OTHER, : <br /> CO <br /> Received by D toReceipS No. Permit No. Issuance Date Mailed Delivered <br /> r 1641 E.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 952U1 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ` <br />