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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) 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 N me (DBA) Address <br /> aOwner -k <- Address_ �' _ R <br /> Firm Partners, Addresses and Telepho a Nu�m} ers <br /> IL <br /> Business Telephone No. - ,' n_ �*7 f Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) C I i Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 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 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <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 �I <br /> 4. SANITATION PERMIT \ <br /> Job Address/Location <br /> O ner � �� � .� Address r � Lv ti C , <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD !a� SEEPAGE PIT ❑ PACK GE PLA 'T <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <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. �V <br /> Homaownarorfleen.ed nt'rssgnatu,eaertHtssdw}pllowlry;"icertifyyt?IttgRtfilepC mattCeOtthe work*whichthis permit isissued,fshall not employ any person <br /> In such manner as to t18CI]fttg subject to woriimant s c mill"aficm laws of Cetifofr:ia <br /> CantTaetors losing or sub.contraeting s;jilurb a certifies titre f6tknoiny; 1 ccrtity that In the perforrlaReo of the work tar which this permit is issued,t shafl <br /> employ persons sublKI tc wofkmari s camperlsation laws of Calihamia.' <br /> hereby certify that I have repared this application and that the work will �e done in accordance Wttt1 San Joaquin County <br /> ordinances, state laws, an r les nd r ul tioins Ve San Joaquin Local Hirth District. <br /> APPLICANT'S SIGNATURE X `- <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> _r.w AMOUNT <br /> FEE 4� <br /> LESS <br /> PRORATION <br /> PLUS / <br /> PENALTY �iAA,� '��U��!}p 2— <br /> OTHER <br /> OTHER <br /> Received b Date ReceipTNo. Permit No. IssuhncA,2!3 Mailed Delivered <br /> APPLIC T—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo=2009 STOCKTON,CA 95201 <br />