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r 1 Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> f� APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> F <br /> Application is ere made cp buC s in the jurisdictional area of the S&rr L o�qui cal Health_ Dist ' t <br /> C_- <br /> U) Business Na (DBA) Zr�� r dress f— f! +►J <br /> aOwner _Address <br /> J Firm Partners, Addresses a1) Tel honeNumbbers <br /> aBusiness Telephone No. ��� Emergency Telephone No. a <br /> Contractor Licence No, 72 <br /> L Applicants Name (Print, Title &ezA)t_e_ Date dc/6 t <br /> Please cheek 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) r <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. M SANITATION PERM <br /> Job Addresss2 Lr cation <br /> P ", ...._Jn.___ Address <br /> SEPTIC TANK 11 CESSPOOL ' ® LEACHING FIELD 9-SEEPAGE PIT ❑ PACKAGE PLANT <br /> 03'FERMANENT ❑ TEMPORARY ❑'�iEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) __ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 .- <br /> Operator Name T Where Certified <br /> Plant Location <br /> Plant Capacity r No. Units Served <br /> 7. ❑ 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 /> l+cmogvmRrorl3cenyedegal"'sa:Qra,tlre srtff;e5ttsefO:Invirlr�:"Inn-:itV!h?ti 1 Zte�`:,r11^nc�Qfth'!workfrrlhhich:hisperrnitislSS eG"IGh.'.I' !^te!npl0yanyperson <br /> In SLch❑FBr',11er ar to become�u OjEct fo wor'k:natar',5 c `7 1„'65cn,Gi.!3s''�-�5t f")VT'mi <br /> Contrtortar's hiring or suh cantrarling certify that ttt the periumiar�e of the work far which this pe-wit is issued,I shall <br /> employ Persons subject to workman's corrpe.nsati!;n lav: of Cdnfu:nia.” <br /> I hereby certify that I have prepared tis applica n an that the work will be done in accordance with'San Joaquin County <br /> ordinances, state laws es an gulati Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY _ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I &Received By January 31' ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> g DATE DATE REMITTED AMOUNT <br /> FEE .R <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER J. <br /> Received by Date Receipt No. Permit No. Issuance 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 />