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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 /> 9 6 2 - 131A LIQUID WASTE <br /> Application is hereby made to carry on buj,5�,_I["1 ess in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) Lia�r• r z 5"Lf <br /> o[i..t.c 44!e Address <br /> aOwner ' Address t7 S <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. Emergency Telephone No. . <br /> -i Contractor Licence No. <br /> d �ith, <br /> Title Date-(• !cL 19 k 2 <br /> Applicants Name(Print) <br /> Please check Applicable Category (1-7) and Fill Required�Ilfolm`atlol <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. ❑ 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.G.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location eLzAau7 <br /> Owner - Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER -� <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> 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 /> Operator Name Where Certified r,� <br /> Plant Location <br /> Plant Capacity 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 /> llfome owne.n.rtosnsee.g.r►t`w shm,tura.,e ratwsthe st►newing "f certtty ttlatrrtfrs perfer[rancsctiheuvorR torw�l fchttlis ptnaifisissW,Fshaif noternpioyany person n <br /> in such mann&w.fobeeoma SuMecl to writfcMar?s compensation laws ofCaliternia! <br /> Contractor's of sub-contract;ng "naturer�atici�s the foaowtoQ: "I rete y that In the performance of the work tet which This permit is Issued,i ahai1 <br /> employ persons su t to vrorkman's compensation laws of California." <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, andules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE Xc <br /> q 1570 <br /> FOR DEPARTMENT USE ON <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH a ary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING ANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE •i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> r <br /> OTHER <br /> . ---t <br /> OTHER <br /> Received by Da a Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />