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Applications Will Be Processed When Submitted Properly Completed. BeSureTo sign IneApp1mauurr. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereb ml�.de to carry on business in the jurisdictional area of the San aquin Local Health District <br /> 7 <br /> Or Business Name (DBA) <br /> Address <br /> z Owner <br /> Address <br /> 4 <br /> Firm Partners, Addresses and Telephone Numbers <br /> rL Emergency Telephone No. <br /> a4 Business Telephone No. <br /> -J Contractor Licence No. _ / - _ <br /> Applicants Name (Print) :/'U � Title � �� - Date--T—� <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. 11 PUMPER YARD <br /> For July 1, June 30, 19 0 <br /> No. of Vehicles Stored <br /> No. of Chemica[,Toilets Stored <br /> s <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or A.C.E. Name R.S.or R.C.E. No. <br /> Test Location <br /> Test Date/Time <br /> _ <br /> 4. ❑ SANITATION PERMIT +- - <br /> Job Address/Location <br /> F <br /> AddressPTIC TANK ❑ CESSPOOL EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ REPAIR ❑ OTHERERMANENT ❑ TEMPORARY _ . ❑ NEW +� <br /> 1 � E <br /> 5. ❑ CHEMICAL TOILETS For July 1,id'One 30, 19 <br /> Type Construction 4 i Disposal Site <br /> No. of Units,-- Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For.July 1,- June 30, 19 - r <br /> Operator Name _ ; - Where Certified <br /> Plant Location <br /> Plant Capacity ji No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> - s <br /> SIZE: ❑ Less Than 1,000 Sq. F Q­IVIO q Than 1 000 Sq. Ft.y __ -- ----- - <br /> ❑ DRY CLEANING, Chemicals Used/Amourrtl`Mo. <br /> Home owner or licensed Jv part'salgnaturrr000ifiRgthefotlowlrtg"I^ertifvthn!inthepertormanceoftheworkforwhichthispermitisissued,Ish311notemployanypei, in <br /> in such manner as to ber-jrl a st<bje,-+to s,cr'..r„'. ;=In ar.=;!tiez sats�f�,<�litn.I:i l <br /> Contractor's hiring or sis_T-scn1r�t,prq ;i,nR1Vrc zsrtia<rs ih� Yu;0*,Jing: "c certify t"t lit the peffofT 3iice of fl,e'Il:r€ `,Cr Y:�', l;f`.i�p:,Mit I5'ISSued,I Shall <br /> employ persons subjt;c�:c IrcricMai$i Lomptnauiie7o laws of Caliis,�riia. t A <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 rules a re cations oft San Joaquin Local Health District. ! � <br /> % t <br /> APPLICANT'S SIGNATURE ' <br /> —FOR-DEPARTMENTx"USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January l &Received By January 31 ❑ July 1 &RecIT <br /> eived By July 31 . <br /> EMIT <br /> BILLING REMITTANCE C-1; $ <br /> AMOUNT DUE CHECKED <br /> BASE EXPLANATION :BATE 'S. DATE REMe - AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> A60 9- <br /> Received by Date Receipt No. Permit No. I uance Date Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. AZELTON AVE.,P.O.Box 2009 STOCKTON,GA 95201 <br />