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----..... Applications Will Be Processed When Submitted Properly Completed.BeSure 1o 51 n Ine <br /> APPLICATION <br /> (For Non-Transferable;Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH;PERMIT <br /> LIQUID WASTE <br /> r <br /> Application is hereby ode to carry on business in the jurisdictional.area of the San Joaquin Local Health . <br /> N Business Name (DBA)ley Address r' <br /> 4 Owne11 <br /> r Addres <br /> J Wee <br /> Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> D. Business Telephone No. <br /> Contractor Licence No. Title o `�Y Y Date <br /> Applicants Name (Print) <br /> i Please check 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) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD ; <br /> For July 1, June 36, 19 - <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name - <br /> Test Location Test Date/Time <br /> G ❑ SANITATION PERMIT0,007 <br /> 'Job Address/Location <br /> O 'C Address <br /> Owner <br /> C1 SEPTIC TANK " CESSPOOL ❑ LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> '❑ PERMANENT ❑ TEMPORARY ❑'NEW _ E] REPAIR �THER <br /> 5. 11 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 ' -Where'Certified <br /> Operator Name <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 /> Home owner or licensed agent's sigtn.4ture crrtifiesthe'.oltoWin§:"I certify that In the performance of the work for whieh this permit is issued,I shall notemploy arty pefson <br /> in such manner as to became sub#eci t{3 V.'Ufili':1$i4S l:^m�1cn`_�ti4n1�14:'S ei Ca%If,',ril?8 , <br /> Contractor's hirings or aub-contrasting) signa±u9' cercite6s thr fotsovri+a: "14certifiy that inthe performance of the evbrk for tiwhlch this permit is issued,l shall <br /> employ persons subject to workman's compensation latiFas of Caliior;:ia." 7 , <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, and rules d regulations of the San Joaquin Local Health District. _ T <br /> APPLICANT'S SIGNATU E X T <br /> A <br /> i <br /> FOR.DEPARTMENT USE-ONLY <br /> Fee IS Due: 11ANNU_ALLY _ ❑ PER UNIT' ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Receiv REMYITuIy 31 <br /> U <br /> Y ;;BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 'BASE EXPLANATION DATE_- - DATE REMITTED - AMOUNT <br /> FEE <br /> LESS F <br /> PRORATION s <br /> PLUS l r ) r <br /> ° PENALTY <br /> i4 OTHER <br /> OTHER - <br /> ' ,, s <br /> Date Receipt No*' Permit No. issu a ate Mailed Delivered ; <br /> Received by - 1$01 E.HA AVE.,P.O.Box 2009 STOCKTON,CA 95201 =jr <br /> . APPLICANt—RETURN ALL COPIES TO:• ENVIRONMENTAL HEALTH PERMIT/SERVICES` <br />