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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 WA5TE'� - <br /> Appl icatiorl is s made t rrxysl iness in the jurisdictional area of.the San Joaquin-Loc ealth District <br /> rBusiness Name BA} +� + t.;Addre4ss <br /> -. �Q —5- - <br /> z Owner Address.,.. <br /> q 4-, <br /> Z Firm Partners, Addresses and Telepho a Numbers <br /> IL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date ` - <br /> f�. <br /> t Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) U� <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 PP Gal.,Weights 8 Measures No: <br /> Equipment Parking Address S�6 <br /> 2. ❑ PUMPER YARD <br /> } w <br /> For July 1, June 30, 191 <br /> t <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Sfored�p <br /> 3. ❑-PERCOLATION TEST d�i <br /> R.S. or R.C.E. Name 1_ R.S. or R.C.E. No. <br /> Test Location hh Test Date/Time <br /> 4 4. A SANITATION PERMIT S� <br /> r Job Address/Location <br /> Owner I oe 2P LlAddress <br /> El SEPTIC TANK © CESSPOOL �EACHING FIELD -C3 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW FoeREPAIR OTHER �jp(/a p!/.-I, <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units r AEquipment Storage/Cleaning Location(s) j k <br /> 6. ❑ PACKAGE TREATMENTLANT For July 1, -June 30, 19 $ j <br /> r .; `"° t Where Certified <br /> Operator Name - � <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. 11 LAUNDRY For July 1,-June 30;.19. <br /> SIZE: El Less Than 1,000 5q Ft.,, 11 More Than 1,000 Sq. Ft, f f <br /> ❑ DRY CLEANING;Chemicals `sed/Amount/Mo. [ <br /> T Hameeowiierorlicensedagent'ssignature certifiesthe follovAnq-1tartifythat!^the performance0fthework for which this permitisissued,tshall not employ any person <br /> in such manner as to becUrn" object to:>rorkrna i s comnerrs:.tior,fawY tt a!ifert„' <br /> Contractor's hiring or m is rortrawfig-eignatutc certifies 2:a1 `"Lagoing: "i;"C -that iri the performance n€the work for which this Permit is issued.I shall <br /> employ persons subject to wIbtkmari s compematiorr iavws of California," <br /> ' I hereby certify thatl�l have prepared this application and that the-work wilt be done in accordance with San Joaquin County <br /> ordinances, state laws, an_d rut and regu tions o the San.Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X �� t <br /> ',JIII j. FOR DEPARTMENT USE ONLY <br /> Fee Is Due. ❑ li.ANNUALLY C1 PER UNITi ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE., DATE 'REMITTED I AMOUNT DUE CHECKED v <br /> AMOUNT <br /> FEE <br /> LESS JI f <br /> PRORATION n� j r <br /> ` PLUS <br /> PENALTY <br /> OTHER <br /> OTHER t <br /> (� 3 <br /> Received by Date Receipt No. Permit No. Issu4 nce DatA Mailed Delivered <br /> 9 <br /> - APPLICANT-RETURN ALL COPIES TO: }ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 -'STOGKTDN,CA 95201 <br />