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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 /> a ENVIRONMENTAL HEALTH PERMIT <br /> LIQUIQ WASTE <br /> Applic n is hereby made carry n business in th jurisd' tional area of th a Joa in.tocal He lth Distri t, <br /> r .-. 4. - <br /> mBusiness a (DB Address <br /> i <br /> Own e Address <br /> A <br /> Firm Partners, Addresses and Teleph _ e Numbers <br /> Q. Business Telephone Na. Emergency Telephone No. — <br /> Contractor Licence No. 2 Z -_ <br /> L Applicants Name(Print) Title. • Date <br /> Please check.Applicable:Categ (1-7)and Fill in the Required Information <br /> 1. ❑PUMPER i14_1 E PERMIT REGISTRATION (FOR EACH VEHICLE) C <br /> For.Juiy 1, ZJune 30,°''-19 - Disposal Sites ) '. <br /> Description(Make/Yr., Color) <br /> 4. <br /> Serial No ' %�'� = w4 �' CAL. License No. CAL. License Renewal No. 1 gyp. <br /> r: <br /> Capacity , N- Gal., Weights & Measures No. <br /> Equipment`Parking`AddressJ � <br /> 2. .0 PUMPERNARD <br /> For July;1, June 30, 19 ` <br /> No:+of Vehicles-Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST - e <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT t.. <br /> Job Addre /Locatf n J <br /> O�wnr- <br /> _ Address ZZ� a <br /> If'l SEPTIC TANK 11CESSPOOL DCEACHING FIELD BSEEPAGE PIT ❑ PACKAGE PLANT <br /> L9 PERMANENT ❑ TEMPORARY ❑ NEW VIREPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 (y� <br /> Type Construction Disposal Site tx�] <br /> No. of Units! Equipment Storage/Cleaning Location() u <br /> 4. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name <br /> Where Certified <br /> , r , <br /> (Slant Location <br /> Plant Capacity �� N .Units Served <br /> 7. ❑ LAUNDRY For July,1, -June 30, 19 <br /> SIZE: ❑ j ess Than 1,000 Sq. Ft., ,'❑ More Than 1,000 Sq. Ft. J' <br /> ❑ <br /> r f DRY CLEANING, Chemicals Used/AmounUMa. —. � <br /> Home owner orticensed agent's signntura certifies the totlow+ng:1 cert ifyy that in the#eriormanceat the work for which this permit is issued,f shall not employ any person <br /> in such manger as to become subleet to workrnaii s compensation laws of Califorhia.' / I T <br /> Cohtrector's Wing or sub-contracting signmtute certifies 'Vie foitovAng: 1 certify that in-the performance of the work for which this permit is issued..)shalf <br /> employ persons subject to woikman's compensation taws of California." +a i <br /> `tt .1 hereby certify that I have prepared this application and t1hat the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rul and regulations o the rrJoaquin Local Health District. f i <br /> G { ;- <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMEN7`USE-0NLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH '� ❑ `January 1 &Received By January'31 El 1 $ Received By July 31 <br /> REMIT <br /> LING REMITTANCE $ ' <br /> BILA <br /> BASE EXPLANATION ` AMOUNT DUE CHECKER <br /> �DATE DATE. REMITTED �i •� � AMOUN <br /> -'LESS <br /> („PRORATION <br /> PLUS ' <br /> PENALTY <br /> i OtHER - <br /> OTHERS j <br /> a <br /> Received by Date I Receipt No. Permrt e s un a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH-PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O:Box 2009 STOCKTON,CA 95201 <br />