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Applications Will Be Processed When Submitted Properly.'Completed. Be Sure To Sign The Application. <br /> ' APPLICATION <br /> v' (For Non-Transferable, Revocable,and Suspendabfe) ` SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Na a (DBA) iN Address - <br /> P <br /> Owner I i �� .i•__ Address- / ®fd <br /> 1 Firm Partners,Addresses and TelIe�o a Numbers <br /> 1 4 Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. .. . <br /> Applicants Name (Print) eS, 1/ ..:5Td�✓� Title.. Date- <br /> Please check Applicable Category (1-7)and Fill in the Required Information,-.: . <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 4 <br /> For July 1,--June 30, 19i = Disposal Sites- <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity �III Gal., Weights & Measures No. <br /> Equipment Parking Address i6 <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 191 <br /> No. of Vehicles Stored <br /> .No. of Chemical Toilets Stored Jill. <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name �♦ R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> � ❑ SANITATION PERMIT <br /> ,% Addre s/Location Dqws )z'-.D <br /> Owner + i Addressf-s grey <br /> SEPTIC TANK ❑ CESSPDOL LEACHING FIELD 0-SEEPAGE PIT 1:1 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPpiRARY XNEW ❑ REPAIR ❑ OTHER V- ;, i <br /> 5. ❑ CHEMICAL TOILETS For Jul 1, -June 30, 19 <br /> July e. <br /> Type Construction �N Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) p <br /> 6. ❑ PACKAGE TREATMENT tLANT For July 1, -June 30, 19 <br /> Operator Name I�r __ — Where Certified <br /> Plant Location '-Y.. <br /> Plant Capacity t * YL _ No. Units Served.' <br /> 7. ❑ LAUNDRY For July 1 hone 30, 19 _ . <br /> ,SIZE:. ❑ Less Than 1.,000-8q'MFt., ❑-More•Than-1,000•Sq�Ft. <br /> ❑ DRY CLEANING, Chemictal's Used/Amount/Mo. ' <br /> Homeowner or licensedagent'ssignaturecertifies the following;"Icertify that lnt,9eperformarceof hework,ior'whichthis permit isissued,Ishall notemployanyperson <br /> in such manner as to become subject to iaotkman's coMpersation.favfs of California_' <br /> Contractor's hiring or mib-coni lcting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman s compensation laws o)CaGfcr <br /> I hereby certify that I have prepay this appli a 'o and that the work will be done in accordance with San Joaquin County t <br /> ordinances, state laws:and rules nd regulatio oagt4fl4_-�alth District. C>p <br /> ' APPLICANT'S S1GNA <br /> IYAII FOR DEPARTMENT USE ONLY _ <br /> Fee Is Due: ❑,ANNUALLY I; ❑ PER UNIT © PER SITE ❑ EACH ❑ January 1 &Received By Januar 31 ❑ Jul 1 &Received R Jul 31 <br /> REMIT <br /> - Y Y Y Y <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED. AMOUNT <br /> � f.! <br /> FEE S- A+.8471 .. ,. <br /> LESS f6 i <br /> PRORATION II� <br /> PLUS i <br /> PENALTY <br /> OTHER i�yl <br /> OTHER �II. <br /> Received by Date Receipt No. Permit No. Issuance 04aLe_> Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ,�{ <br /> _ III C6 <br />