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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> Z,� (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> {" <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is yyr ie to c ry on Laei in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Na BA) i Address d< <br /> z Owner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> IL <br /> Business Telephone No. Emergency Telephone No. <br /> � <br /> Contractor Licence No. <br /> L Applicants Name (Print) e S4ftA4 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) CIA\ <br /> Serial No. CAL. License No. CAL. License Renewal No.. <br /> Capacity Gal., Weights& Measures No. <br /> Equipment Parking Address t <br /> 2. ❑ PUMPER YARD I <br /> For July 1,- --- June 30, 19--- <br /> No. of Vehicles Stored <br /> i <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. f <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT _ <br /> Job Address Location <br /> Owner C- Address <br /> E] SEPTIC TANK E] CESSPOOL ❑ LEACHING FIELD SEEPAGE PIT 13 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW Ai�REPAIR ❑ OTHER 0 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 r <br /> Type Construction Disposal Site tD V f <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 5. ❑ 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 �J <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000,Sq:,Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Nome owner air geensed egent'a sEgnatelre cer_ifissttro foU9wing:"t certtfy that in the perkirmanre of thewort;for wNch this permit is issued,I shalt not employ arty person <br /> in such manner as to become subject to workman's compensation laVvB nl Gali,or,:O ' t <br /> Gontraator's hfri or rub-contracting signature castifies 'ta totwwing: 1 oris'•,t!a?i^the pe forniance of the work for which this permit is issued,I shatl <br /> employ persons subject to workman's compensation taws of Cafitornia." <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rule d regulations of the <br /> San Joaquin Local Health District. 1 <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 /> w. RASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE C s s <br /> LESS A' i <br /> PRORATION V <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �3 /6 13 yy o <br /> Received by Date Receipt No. Permit No. Issuante Date Mailed livered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.Q.Box 2009 OCKTON,CA 95201 <br />