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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplica ion. <br /> APPLICATION <br /> I (For Non-Translerable; Revocable,and Suspendable) SEPTAGF <br /> rill ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio is her by de carry sine the jurisdictional area of the San J&91in Lo I Healt Distr'ct <br /> Add(ess <br /> Business Na BA) <br /> `z Owner `. y Address <br /> s / <br /> Firm Partners, Addresses and Tel In N 3bers Emergency Telephon�No.. <br /> v t <br /> ala Business Telephone No. L <br /> 3r <br /> I a Contractor Licence No. Date . �" <br /> Title. j <br /> !� LAPPlicants Name (Print) M " <br /> „ t <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> j 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH'VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites' <br /> Description(Make/Yr., Color) . CAL. License Renewal No. <br /> rtei <br /> Serial No. CAL. License No. <br /> - '•k- , 3�T•'.� ',.x...,•ewac "y;�y :.L';n.k "'"""�.° 0.A <br /> i; Capacity Gal.,Weights`& Measures No, <br /> Equipment Parking Address ' <br /> E� 2. 0 PUMPER YARD <br /> it <br /> ii For July 1, June 30, 19 <br /> li No. of Vehicles Stored ^..�` i .� _<� - - <br /> ` <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST �R.S.S.or R.C.E. No. <br />' R.S. or R.C.E. Name <br /> f <br /> TTest Date/Time <br /> Test Location <br /> t .. � , �� G <br /> q. SANITATION PERMIT <br /> I Job Address/Loc .on 1 3 317 <br /> Owner A Id,%s ❑ PACKAGE LANT <br /> L 4 W <br /> ,l 3 SEPTIC TANK CESSPOOL O LEACHING FIELD SEEPAGE PIT <br /> d15ERMANENT 11 TEMPORARY N�-11EW ❑ REPAIR ❑ OTHER _J <br /> 5. <br /> ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> i 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 /> s' Where Certified <br /> ° Operator Name - } <br /> s Plant Location <br /> t No. Units Served <br /> Plant Capacity <br /> 7. 11 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 /> Homeownerorticensedag9nt'Ssignature¢ertaie5theiollewing_"1certify thatinTt@perfotma-nreoftheworkforwhlchibispermitisissued.Ishallnotemployanyperson <br /> in such manner as tc:become subfecito workinan:s cginpehsatian la.•ds at Ca iforr ia' <br /> Contractor's firing or sub-contracting signat'ure'cw Bfies!tha #oltnivinq: I certify Oa{in the perfcrmanrE ci the work for which this permit is issued,l shall <br /> employ pers6ns subject to workman's compensation Paws of Caiifornsa , t - r le, <br /> hereby certify that I have prepared't. ti and that the work`will be done_in accordance with San Joaquin County <br /> ordinances, state [a', , a rul n 'San Joaquin Local Health G`istrict.- ` <br /> APPLICANT'S SIGNATUR --y <br /> S FOR DEPARTMENT USE ONLY <br /> 4 Fee IS Due: ❑ ANNUALL El UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 E] July 1 &ReceiveRdEB^yl July 31 <br /> i BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> SASE EXPLANATION DATE DATE REMITTED �f AMOUNT <br /> FEE <br /> � h <br /> LESS r <br /> PRORATION <br /> PLUS ; t <br /> PENALTY <br /> -OTHER tk <br /> OTHER <br /> Received by �'� <br /> Date Receipt No rmit No. ssuance Hate Mailed Delivered <br /> APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE., 95j � <br />