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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> 1 (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicationhereby made to carryon buses' ess in the jurisdictional area of the San Joaquin Local Health District <br /> .isOF Business Name (DBA) �/�. /�i4Rl2.CS'� �" So.yf Address /�� /a- le-SM :5� <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> -a. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. 4—�-393 <br /> Applicants Name (Print) �! Title �S�� Date 'A0"8 Z <br /> Please check Applicable Category 0-7)and Fill in thelfiecluired Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) N <br /> For July 1, June 30, 19 Disposal Sites f <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. 9 SANITATION PERMIT /1 <br /> Job Address/Location 278 Y9 <br /> Owner7 lLi4 2/r! Address si4�TJ� m <br /> SEPTIC TANK ❑ CESSPOOL JR LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW JgI REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site A <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 <br /> Plant Location <br /> Plant Capacity No. Units Served y}- <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 /> Noma owner or licensed r.9enr'ssignalunDclrtlf'ovthe fc`"wiexr"IC^rtify:hntinthe perfOrmanceoftllemorx ,0 c,hihisperrr,i' issues ?flno!em�io ar.yHers- <br /> in such manner as to become subject to workmawl orrtpe 1 .tl ri fo;;of Galif"a,' <br /> Contractor's hirlinill Or etltl-contracting &:gnat4r* cordflies VW flprpyyl�: "f{pr�jf�rtll3itii i'!' yt;Gr' <br /> employ persons subject to warkrnalt's compeasatioo laws of Calitamia,, <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 and regulations of the San Joaq Local Health District. <br /> APPLICANT'S'SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE " <br /> LESS <br /> PRORATION <br /> PLUS ^ <br /> PENALTY �' r <br /> OTHER <br /> OTHER <br /> b Z3 o i <br /> Received by Date Receipt No. Permit No. Issuanceate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES- 1601 E.HAIELT .,P.O.Box 2009 STOCKTON,CA 95201 <br />