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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheAPpucanon <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> . ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Application i mad t ca business in the jurisdictional area of the San Joaquin Loc ealth Diic <br /> 4 Address sp <br /> UF Business N (DBA ' <br /> _ Address _ <br /> a Owner <br /> q,Firm Partners, Addresses and Telephone Numbers <br /> C6 Business Telephone No. Emergency Telephone No., " <br /> �. <br /> a Contractor Licence No. <br /> Applicants Name(Print) - _ Title �� Date <br /> Please check Applicable Category.(1-7)�and Fill in the Required.Information,_ <br /> 1. 13PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, - June 30; 19 Disposal Sites. - `] <br /> Description(Make/Yr.,Color) w <br /> e No. CAL.License Renewal No, <br /> Serial No. CAL. Licens <br /> Capacity ` Gal:;Weights &Measures No. - <br /> P <br /> Equipment Parking Address # <br /> 2. ❑ PUMPER YARD f d <br /> For July 1, , June 30, 19, <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. or R.C.E. Name - ,�- <br /> Test Location t - N Test Date/Time <br /> 4. i�-.ANITATION PERMIT 2 <br /> Job Address/Location oc <br /> Ownero9desk" Q 1 D.A n� Address <br /> SEPTIC TANK 13 CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑'PACKAGE PLANT - <br /> ❑"PERMANENT ❑ TEMPORARY ❑ NEW REPAIR C1 OTHER �� t <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> i Type Construction' Disposal Site <br /> No..of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity <br /> 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. k <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> 1 <br /> E <br /> Home vwnerorlicensed agent's ITgneturecort fee the folkyjomo:1rR.t11i",ira}'nlhpPerfo-raidnceoftftew4rkfnrvr"ichthispe�mhlslasued,4shalln8tempinyeAyper�cm <br /> E in such manner as to be(mme subject to i4'C f S[T a:? v-`I, r Sr't'jli?' "r G.',:i.ti"i t. <br /> Contractor's hiring or sub contracting Signature cartifles chi iifiioYJi�t�.i"f c8rtify it 3t.1 Yk perionnance of the work for which this pertnit Is l�stled,i shall <br /> employ persons subject to workman's compensaliun laws ut Calltornia:' i <br /> k I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> l ordinances, state laws, and rules regulatio f t San Joaquin Local Health District. <br /> f <br /> APPLICANT'S SIGNATURE X T <br /> i FOR DEPARTMENT USE ONLY <br /> E Fee IS Due: 13 ANNUALLY ❑ PERUNIT ❑ PER SITE EI EACH ❑ January 1 &Received ByJanuary31 ❑ July 1 &Receive RdMITuly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION - DATE r DATE REMITTED AMOUNT <br /> LIZ— <br /> FEE <br /> LESS <br /> r PRORATION ' <br /> r PLUS i <br /> PENALTY <br /> OTHER ,.� - ." '"' -�"1" t r--•.F .... , <br /> k; <br /> OTHER --- <br /> t - _�7 <br /> t Date Receipt No. Permit No. issuance Date Mailed, Delivered <br /> Received by <br /> " APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1641 E.HA2ELTON AVE.,P.O.Box 2449 STOCKTON,CA 95201 <br />