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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable;Revocabie,.and Suspendable) SEPTAGE <br /> 1 ENVIRONMENTAL HEALTH PERMIT <br /> G LIQUID WASTE <br /> Application I'&her by m de t arty on.4aupiness in he jurisdictional area of the San Joaquin Local Health Di�itrict��` <br /> NBusiness Name (D AJ Q � { Address <br /> z Owner Address S4 Frl t=d <br /> a <br /> Firm Partners, Addresses and Tel hone Numb rs <br /> aBusiness Telephone No. REmergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title `� f t) Date <br /> Please check Applicable Category (1;7)_and Fill in the Required Information <br /> � . <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) l <br /> For July 1, June 30, 1.9 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity A Gal.,Weights S 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 /> r <br /> 3. ❑ PERCOLATION TEST + <br /> R.S. or R.C.E. Name " _ R.S. or R.C.E. No. <br /> k Test Location y Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Locationc)77 4 <br /> OwnerAddre s <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT. �g�p <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW + ❑ REPAIR ❑ OTHER 60♦ u, <br /> ° 5. E] CHEMICAL TOILETS For July 1, -June 30, 19 R ��� I;t"4x -� <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 �33J �7 <br /> Operator Name ---- 1 Where!Certitied <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. A <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ro <br /> Homeowner ortiaensedagant'ssigrwilumcertit4c�KthefalloarTrt#:"IeertlrythatintheperformanceoftheworktDrwhichthisperniitIsissued,Ishall notemployany Demon <br /> in such manlier as to become subjeel to workmali:jfx ponsattioil laws o!Calimmiz <br /> Contr0Ctor s hiring OF sub-coeltraating signatum cot Wies dw toltowing: i i trYs t..tlat 1,1 1he performance of the viork far which this permit is issued,I shall <br /> employ persons subject to w,urkmaris compensafi>:n lacus of Cialifai Rim" <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 an reg lations of the San ii aquin Local Health District. <br /> O 1, 2 <br /> APPLICANT'S SIGNATURE X -. ' <br /> p ea, Z 4- tfi <br /> r r FOR DEPARTMENT USE ONLY <br /> t <br /> F@@ IS DUs: ❑ ANNUALLY ❑ PER UNIT. PER SITE 11 EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE _ $ REMIT <br /> t BASE EXPLANATION AMOUNT DUE CHECKED <br /> f r DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER f <br /> OTHER - -� -- - <br /> Received 6y Date Receipt No, - Permit No.. Issuance Mailed - <br /> livered <br /> APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEL _t ..,P -21108 STOCKTON,GA 95201 <br />