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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 1 <br /> APPLICATION <br /> ^ (For.Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> lZ {l J1 -ENVIRONMENTAL HEALTH-PERMIT <br /> L� LIQUID WASTC y <br /> Application i made to a o i ss in the jurisdictional area of the San Joaquin oval H Ith District <br /> HBusiness Name (DBA) Address 1 <br /> 4 Owner llzAddress <br /> .r <br /> Firm Partners, Addresses and Tel hone Number/ss <br /> aBusiness Telephone No. _ � �G Co Emergency Telephone.No. t <br /> a Contractor Licence No.4 _ } <br /> L Applicants Name (Print) f o 1 Title - Date <br /> 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,_ti.-- June 30, 19 -Disposal Sites - - --- - - - - s <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 r <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored = <br /> 3. Q PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. t i{ <br /> Test Location Test Date/Time <br /> 4.% SANITATION PERMIT <br /> Job Address/Location t <br /> Owner ef:::es-," F�- � Y Address <br /> ❑ SEPTIC TANK. ❑ CESSPOOL. ❑ LEACHING FIELD JKSEEPAGE PIT PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY [--]...NEW i ,'REPAIR ❑ OTHER ' <br /> 5. ❑ CHEMICAL TOILETS For July 1, June 30, 19 r � <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 rn 1 <br /> Operator Name - Where Certified^ ' <br /> Plant Location . <br /> Plant Capacity No. Units Served a <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More'Than 1,000 Sq. Ft- r. <br /> ❑ DRY CLEANING,Chemicals Used%Amount%Mo. _ t <br /> -�­Homeownernrticenaeo!spent'asignature c-orlest?aefollo+e°sng:"ICrrtifgi!i i7ttte�e:�rm�nceflffilewvtkl�r%Vhichth':s'pormifisissued,lshall not employany Ito= <br /> in'swo mannef as to becom8 subject to workman's cempensa,i:y1 ^.tirS of caiife sd <br /> j Contractor's hiring or s+>b-contracting signature,Geri f es the-fouowinq:_'1 certify that in the performance of the work for whiCh this permit is issued,f shall <br /> employ persons subject to warkmari s compensation laws of Caiitornia:' <br /> I hereby certify that l'have prepared this'application and that the work will be done in accordance with San Joaquin County <br /> I ordinances, state laws, and r nd regu tions the San Joaquin Local Heath Ristrict <br /> APPLICANT'S SIGNATURE <br /> ym <br /> t FOR.DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By,January 31 ❑ July 1 8 Received By`July'31 <br /> —{ . .... REMIT <br /> + BASE EXPLANATION +' BILLING REMITTANCE -r$ F .AMOUNT DUE CHECKED <br /> t DATE DATE REMITTED. y---AMOUNT <br /> FEE '�! _ k .r_r^ <br /> , 1 <br /> LESS ` <br /> PRORATION - ? <br /> PLUS <br /> -PENALTY <br /> OTHER. <br /> OTHER } <br /> Received by Date 'Receipt No. Permit No, Is uance Date Mailed Delivered i <br /> APPLICANT=RETURN ALL COPIES TO-"- ENVIRONMENTAL HEALTH PERMIT/SERVICES+" 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> • I7 <br />