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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> I (For Non-Transferable;Revocable,'and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTHYPERMIT <br /> LIQUID WASTE <br /> Application iy9reby made car o usiness in the jurisdictional area of the.San Joaquin Local Health Di trict <br /> OF Business Nam BA) ddress—,� � r� � <br /> / 4 <br /> a Owner 4 zo <br /> ..._- r Address <br /> 9 Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business-Telephone NoT. Z.�g�' Emergency Telephone No, <br /> Contractor Licence No. <br /> Applicants Name (Print) - Tltle Dateor- <br /> i �•i , <br /> Please check Applicable Category (1 7)-and Fill In the Required Information <br /> _ <br /> 1. E] PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, - June 30. 19 =' = Disposal Sites, <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. G_ AL..Lice.nse.Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> t <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 '7— <br /> No. <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> v <br /> R.S. or R.C.E. Name R' No. <br /> or R.C.E. No. <br /> Test L cation_ Test Date/Time <br /> t 4.' SANITATION PERMIT <br /> Job Add ress/Location._ z�cq� J4� <br /> Owner -u r✓- Address _. ' <br /> 13 SEPTIC TANK ❑ CESSPOOL ACHING FIELD C] SEEPAGE PIT 13 PACKAGE PLANT _ <br /> ❑ PERMANENT ❑ TEMPORARY -D;;-NEW _19CREPAIR ❑ OTHER <br /> F 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> F Type Construction u Disposal Site / <br /> No. of Units Equipment Storage/Cleaning Location(s) ) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name i, Where Certified <br /> Plant Location <br /> f Plant Capacity No. Units Served t <br /> ' 7. ❑ LAUNDRY -For July 1, -June 30, 19 <br /> SIZE: Less Than 1,00o Sq!iFt., ❑ More Than 1,000 Sq. Ft. x <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Harnaownerorliccnae3a5�^n4'es�gna°i�rrMGarti4l�S:E1C;4;fOttfi't+ `I•Ers1 1i '.i Cyer ma .r. he.1;orV'6.1NhiChthis�lUmAisissue Ishtl!Rntemployatty�ersGf4 <br /> +!i <br /> r in such manner as to bFGorrc:ut7j° f.t0;NOt;il i l';;fG GF,I:• i�f i NS Ct s ii <br /> Contractor's hiring or sub-CO:ltractirrg signatet;e ccrt:t:e3 the 'cltowa�:g: 1 e ITy 1iiat in the performance of the work for which this perirlii i5 issued,I shall <br /> emptaypersons.subject to workman's compe-nsatto,taws of CViln rla. { <br /> I <br /> I I r hereby certify that I have prep this ap ication and that the"work-will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rul an egula ' ns of th an Joaquin Local Hea Distr' <br /> APPLICANT'S SIGNATURE X _ <br /> - OR DEPARTMEN SE O <br /> —Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANA710N BILLING 1 REMITTANCE $ AMOUNT DUE CHECKED <br /> - -F DATE - DATE s REMITTED - - AMOUNT <br /> FEE <br /> P <br /> LESS _..• <br /> PRORATION _ - ' <br /> PLUS <br /> PENALTY II <br /> OTHER <br /> { <br /> a - OTHER <br /> 444 <br /> Date Receipt N . 9 Permit No Issuance Date Mailed Delivered <br /> Rece;Jed by <br /> P <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES"`- 1601 E.HA2ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />