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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> - <br /> (For Non-Transferable,-Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT + <br /> LIQUID WASTE <br /> Application is ereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District, <br /> ,FBusiness Name (DBA) c� � Address— � -�� P� <br /> aOwner Address ) <br /> Firm Partners, Addresses and Telepbone Numbers <br /> 0. jp S Emergency Telephone No. <br /> a Business Telephone No. ,, - <br /> a <br /> � Contractor Licence No. , �7�,,� <br /> Applicants Name (Print) •. . Title �z Date <br /> Please check Applicable Category (1-7)and Fill i4thequired Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19. Disposal Sites <br /> Description(Make/Yr., Color} :s v_ r, -- rt ' • _ ... �- ..._.. - ., .c-.. _. ___ k - <br /> Serial No. T _- I CAL- License Na- ' CAL. License Renewal No. <br /> f <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. ❑ PERCOLAT16�N TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E.No. .0 <br /> ,Test Location <br /> 9 Test Date/Tim <br /> 4. 4 SANITATION PERMIT e Ki <br /> ,Job Address/Locatio'n•" <br /> t5 6 r� <br /> !Owner Address y C <br /> iO SEPTIC TANK ❑ CESSPOOL IRLEACHING FIELD ❑'SEEP GE PIT ❑ PACKAGE PLANT <br /> 10 PERMANENT ❑ TEMPORARY ❑YNEW ❑ REPAIR ❑ OTHER <br /> s' ❑ CHEMICAL'TOILETS For July 1, -June 30, 1 9 <br /> }Type Construction -V, Site --- --- - - "� <br /> jNo. of Units Equipment Storage/Cleaning Location(s) _ <br /> '6`'-.0 PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> i - Where Certified <br /> kOperator Name <br /> 'Plant Location <br /> I No. Units Served <br /> Plant Capacity <br /> �7. '❑ LAUNDRY For July-1, -June 30, 19J <br /> t <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,. ❑ More Than 1,000 Sq. Ftw - <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> Hams awnerorli�enredagent's^97sr8lAre ce*tifiesthsfollo+wing:"',Cer''iiiyy 4!j.t inure psrforr;�ance of tile work for which this permit is issued,l shad notemploy any person <br /> in such manner as to become subtest to workmilri s compefLsation laws of C'afitornia:' i �'� <br /> Contractor's fieri��++Qq orsub-contracting signature t9rtiiies the fauowing: "I artily that in the performance 01 the work for which-this permit is issued,I shalt <br /> employ persons sunlect to workman s compensation laws of Calilornia" <br /> I hereby certify that I have prepared this application and hat the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and. ules.and regula Qhe. n Joaquin;Local Health District. le <br /> 1APPLICANT'S SIGNATURE X `le <br /> i r <br /> FOR DEPAR MENT USE NLY �G'X.'�f rr' at �� <br /> ( � . v <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT. ❑ PER SITE ❑ EACH ❑ January 1 &Received By, <br /> 31 0 July 1 &Received By July 31 <br /> � � REMIT <br /> ( ,a <br /> BASE BILLING REMITTANCE $ AMOUNT,DUE CHECKED,. <br /> -V4 ' sEXPLANATION - <br /> � DATE BATE REMITTED AMOUNT , <br /> FEEL"t�. <br /> 'r. <br /> 4 r LESS. <br /> PRORATION mow• <br /> k <br /> PLUS"— <br /> PENALTY <br /> LUS"_PENALTY <br /> OTHER <br /> OTHER <br /> { Received by Date Receipt No. Permit No, issuance Date Mailed Delivered <br /> L_4 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTDN AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />