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Applications Will Be Processed When Submitted Properly 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 iylgrebb <br /> made to r on usi ss in,the jurisdictional area of,the,San Joa uin L I He District , <br /> Business N (DBA _ Address <br /> i a Owner _ ._ Address <br /> Firm Partners, Addresses and Telephone Numbers y <br /> aBusiness Telephone No: Emergency Telephone No., <br /> Contractor Licence No. <br /> L Applicants Name Print ` Date <br /> pp (Print) Tltle <br /> Please check Applicable Category (1-7)and Fill in:the Required Information f, k <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> -For July 1, June 30, 19 - - Disposal Sites.W- __ <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, r June 30.-19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored ' ?: + <br /> 3. ❑ PERCOLATION TEST *c #- a. - , ''�. <br /> R.S. or R.C.E. Name ,r. .r R.S. or R.C.E, No. <br /> i <br /> Testi Location �4 Test Date/Time ( ? ) <br /> 4. KSANITATION PERMIT <br /> Job Address/Location 02 e <br /> Owner L1 _. Address i <br /> �` EPTIC TANK ❑ CESSPOOL �I.EACHING FIELD 19ySEEPAGE PITY ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, June 30, 19 <br /> 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 /> 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. <br /> Home owneror licensed 1 certify tltht in tho performance of Me work for Which-this permit is issued,l shall not employ any person- <br /> in such manner as to became subject to workma A's eompensztian f3v,,s of tia!itRrrti<" <br /> Contractor's hiring or sub-contraCtIMP ssrs3aftre CerzWen rr;c sWiow;ng: `t zurtli}thatinthe performance Gf the work for which this permit is issued,I shall <br /> employ persons subject ib workman's compensation laws of Ealiior.l:a." <br /> hereby-certify that I have prepaN this applicat' n and that the work will be done-in accordance with San Joaquin County <br /> ordinances,state Paws, and ruleVlny regulations the S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> gly <br /> LVI J_ <br /> FOR DEPARTMENT USE ONLY .. t <br /> Fee Is Due: 13 ANNUALLY PER UNIT, ❑ PER SITE - ❑ EACH '❑ January 1 &Received By,January 31 ❑ July 1 &Received By July 3 <br /> REMIT <br /> BILLING REMITTANCE - $ <br /> BASE EXPLANATION DATE - DATE_. AMOUNT DUE CHECKEDI <br /> REMITTED <br /> AMOUNT <br /> t� Q <br /> FEE � F _ '•y <br /> LESS <br /> PRORATION, <br /> PLUS I <br /> PENALTY,. <br /> OTHER S <br /> OTHER <br /> -410 <br /> Received by - Date ;Receipt No Permit No.' Issua ce Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/sERYICEs '1601 E.HAZELTON AVE.,P.O.Box'2009 STOCKTON,CA 95201 <br /> 3 <br />