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Applic� actio Will Be Processed When Submitted Properly Completer. tieoucC I +a•• �� ;i <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE 9 <br /> ENVIRONMENTAL HEALTHTERMIT i 4 <br /> It <br /> LIQUID WASTE + <br /> Application is he made to car n busi a in the jurisdictional area of the San Joaquin Local Health Is nc <br /> .i <br /> Address <br /> yBusiness Name (DBA) gddress _ li <br /> z Owner <br /> a <br /> 2 Firm Partners, Addresses and Telephone Numbers i <br /> Emergency Telephone No. <br /> IL Business Telephone No. <br /> Contractor Licence No. Title, Date <br /> L Applicants Name (Print) ` , <br /> Please check Applicable Category-(1:-7)and Fill.in the Required Information r' ('#1 , t 1. <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> for July i,— .-June <br /> 30:19 <br /> Disposal Sites <br /> Description(Make/Yll Color) _ CAL, License Renewal No. <br /> Serial No. CAL. License No. <br /> Weights &Measures No. <br /> Capacity' Gal-, <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 :E. No <br /> � R.C . <br /> R.S.or R.GR.S. or E. Name Test Date/Time <br /> n <br /> Test Location <br /> 4. ❑ SANITATION PERMIT / /14 /2 <br /> Job Adilloca ion �I i <br /> Address p <br /> K1011KI, <br /> r ❑ PACKAGE PLANT <br /> EPTIC TANK ❑ CESSPOOL LEACHING FIELD i�SEEPAGE PIT ❑ OTHER <br /> ❑ TEMPORARY- PIEW <br /> 1-1 REPAIR <br /> ERMANEN7 � � g� °�„' ;'�'� ' <br /> 5. 11 CHEMICAL TOILETS For July 1,-June 30, 19 r .7 li 4 <br /> Disposal Site <br /> Type Construction <br /> No. of Units it 1 <br /> Equipment Storage/Cleaning Locations) (�-I <br /> ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 - <br /> I 6. _ Where Certified � ,i <br /> Operator Name <br /> Plant Location <br /> No. Units Served i <br /> -Plant Capacity <br /> ' 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> ,Si ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq_ft,l l <br /> c ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ) + li <br /> Home owrierorticensedagent• s9gnat+urecertifeesthafeltewl"I Certifythatinthspertormtnreofthewt}rkfor�ahichthisperinitisissued,Ishaftno#employatlypersoni' <br /> I in such manner as to become subjIect to viorl:mari s colnpensa#iolt taws D4 Crilirernla <br /> Contractor's tiring or sub-contracting sionotur+s certifies the i�ilow:ng:°'I certify that in the periornlance o°the work forwhich.ihistperrr;ii is issued,i sfiais <br /> employ persons subject to v,4rkntan's cc ltpeirswtlnn iaws of California." a �j <br /> I hereby certify that 1. have prepared this application and that the work will be_do.ne,in accordance with San Joaquin County ;i <br /> ordinances, state taw , and rules an - gulation of the S Joaquin Local Health District,-4 ; <br /> i <br /> APPLICANT'S SIGNATURE X <br /> r. FOR DEPARTMENT USE ONLY- fir <br /> I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT . ❑ PER`SITE '❑ EACH ❑ January.1.&Received By January 31 �ti: ❑ July,1 &Received By July 31 <br /> `- .. - REMIT <br /> BILL - REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE { ' HATE- REMITTED AM T <br /> FEE- - 'VC <br /> 1 - <br /> LESS - <br /> PRORATION i <br /> PLUS <br /> ' PENALTY <br /> OTHER- <br /> k_ OTHER <br /> r + Mailed <br /> �, 4 , Issuance Date Delivered <br /> D,11 'Receipt No, Permit No- <br /> Y Receive, by : f., 1601 E.HAZELTON AYE.,P.O.Box 2 4 STOCKTON,CA 45201 <br /> APPLICANT—RETURN Al COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />