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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATrOr, <br /> (For Non-Transfera .Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appiic is here�y mad to car ,ort usiness n f .jur dictional area:of the n Joaq Local He th ist i t, <br /> Businesaetdame (DB Address 7 <br /> z Ownerr Address <br /> a _ <br /> Firm Partners, Addresses and Telephone tubers _ <br /> o. Business Telephone No. f Emergency Telephone No. <br /> Contractor Licence No. -z- <br /> AFPlicants Name(Prins), Title r Date <br /> Please check Applicable CatWry(1-7)and Fill in the Required Information <br /> 1. Q'l?UMPEF(VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,,rotor) <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 Loction ' Test Date/Time <br /> 4. SANITATION PER IIT / �- <br /> Job Addre Locat' n - . <br /> Ow z 4::;v Address <br /> Itf,�EPTIC TANK ❑ CESSPOOL ACHING FIELD SEEPAGE PIT ❑ PACKAGE P NT <br /> E PERMANENT 13 TEMPORARY W ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 :.n� i Type Construction Disposal Site " '__ti /J <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> , <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Wher Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ lbess Than 1,000 Sq. Ft., 11 More Than 1,000 Sq. Ft. <br /> DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home owner or licensed agent's signetumcetMesthefonowfne:`'i certify that In theperformanceof thework for which this permit is issued,l shall not employ any pers:' <br /> in such manner as to become subject to workman's compensation laws of California. <br /> Contractor's hiring or sub-contracting signature certifies the lolkswing;-�t Certify that in the performance-ol the work for which this permit is issued,l shall <br /> employ persons subject to workman's compensation taws of Calitornia.': <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, an rules and r lati 'pf the San Joaquin Local Heakh Nkrict. <br /> APPLICANT'S SIGNATURE X _ <br /> FOR DEPARTMENT USE ONLY <br /> 9f <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ® EACH; ❑ January 1 &Received ByJanuary 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION' DATE DATE ED AMOUNT,DUE CHECKED <br /> � AMOUNT <br /> FEE C IF_ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER _ <br /> OTHER <br /> Received by Date Receipt No. Permit No. lissuanci Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.Q.Box 2009 STOCKTON,CA 95201 <br />