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Applications Will Be Processed When Submitted Properly Completed. Be Sure 70 Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applica ' is helebY mad to c ry on usine s' the risdictional area of th�j as Joa in Local Health Distric , <br /> Address'C7AA <br /> m Busin ame (.DB <br /> Address <br /> j Firm Partnes, Addresses and Tel phon Lumbers <br /> tele hone No.. Emergency Telephone No. <br /> 0. Business p <br /> a <br /> Contracts Licence No. Title Date l - <br /> LAPPlicarts Name (Print) <br /> Please-heck Applicale.Caie (1-7)and Fill in the quireli Information. ,� <br /> y ❑PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Fo;u1y 1, June 30,:1'9` - Disposal Sites - <br /> V <br /> Deription(Make/Yr.,Color)" ' ' <br /> h ?`' CAL. License No. CAL. License Renewal No. <br /> Seal No. s _E. <br /> opacity s `� Gal.,Weights & Measures No. <br /> t �t <br /> 7wuipment ParkingAddress,r - <br /> C7,PUMPER YARD T ' <br /> :or July 1, 4 June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> f R.S. or R.C.E. Name <br /> E Tes!Lobation Test Date/Time _ <br /> 4. SANITATION-PER TT—� <br /> Job Add r /Location / <br /> Ares <br /> Owner dds 1 <br /> ❑ LEACHING FIELD - �SEEPAGE�PIT 11 PACKAGE PLANT ! <br /> C1SEPTIC TANK C3 CESSPOOL �,J <br /> ❑ TEMPORARY ❑ NEW �' ❑ OTHER `:; <br /> PERMANENT <br /> 1s�REPA(R "- 1 ► t <br /> 5. '❑ CHEMICAL TOILETS For July 1, -Junf. <br /> �30, 19 � t <br /> Type Construction aDisposal Site {; <br /> Na. of Units <br /> Equipment Storage/Cleaning Location(s) <br /> •.• - .�:� 't;- '-%" i <br /> 6. 11 PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Where.Certified. _ - - <br /> Operator-Name ..-:._ <br /> Plant Location <br /> :--•�- - �---Nb: l�nits-Served`"-: £- � = - <br /> Plant Capacity ' <br /> T. ElLAUNDRY For July 1, -June 30, 19 1 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft, ❑ More Than 1,000 Sq. Ft . <br /> I *_ st <br /> 11 DRY CLEANING,Chemicals Used/Amount/Mo. , <br /> Home ownerorficensedegent'ssignsturet-fifisstf18fetlovving:'y gr11(trth�ttalkie erf rmance6t the Work forwhichthis permit isissued,)shall not employ any Qersan� <br /> in such manner as to become subject to workman's eonlpensation laws of Galitomi4 <br /> Corltrector's hiring or sub eailtracting.signature eerdfias following_ ••t Certify That in the performance of the work for which this pelms't is issued.I shall �- <br /> employ persons subject to workmali s compensation laws <br /> }. � � <br /> I hereby certifyjthat I' have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a rules,ancl r Iati of the San Joaquin Local Health District. 1 ! <br /> APPLICANT'S SIGNATURE X , <br /> CJ <br /> FOR DEPARTMENT USE ONLY <br /> Fee 19 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdE6^'gTulyi3l�'•'- <br /> f BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> rLESS <br /> PRORATION - <br /> ' <br /> PENALTY <br /> OTHER <br /> OTHER / <br /> Received by <br /> Date Receipt No. Permit No. Iss ancepate Mailed Delivered <br /> APPLICANT—RETURN ALL COPI"To ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTOIA AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />