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" —Applications Will Be Processed When Submitted.Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION- <br /> ' f (For Non-Transferable, Revocable,and Suspendable) SEPTAGE - <br /> 1\ ENVIRONMENTAL HEALTH,PERMIT <br /> 1 <br /> e LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) Address <br /> z Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. .- ..3 .Emergency Telephone No. <br /> Contractor Licence No. <br /> j.. Applicants Name (Print)—����i J ` �QA �LC�, T 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, - June 30, 19 - Disposal Sites 1 <br /> Description(Make/Yr., Color) r <br /> Serial No, CAL. License No. CAL. License Renewal No. F <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address. <br /> 2. 13 PUMPER YARDFor July 1, June X-19 <br /> No. of Vehicles Storetl i� 4 — <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST r <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> t Location Test-Date/Time <br /> A. rEPTICTANK <br /> PERMIT <br /> t Jon <br /> Ow4 Q S• At,) <br /> ❑ ❑ CESSPOOL ❑ -LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT❑ ❑ TEMPORARY 1 ❑ NEW S- ❑ REPAIR ❑ OTHER <br /> 5. CHEMI IOLI LETSFo Juty�lune 9 <br /> Typ Construction 1 Di posal Site <br /> No. of Units Eqb pfnent Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19_ , <br /> Operator Name Where Certified! i <br /> Plant Location J '` € CA <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 i <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo- <br /> f- r <br /> Home owner or licensed agent's signature certiffesthe fullovAng-"I reirtify thatin tiiePerformance of the work f or which thig pafmit is issued,I shalt not employ any persan <br /> in such manner as to become subject io werk;pan',compensation I,1ws of California" <br /> Contractor's hiring or sub-contracting signature certifies the fotloruing: "I Certify that to the performanco of the work for which this pertmt is issued,J shall e <br /> employ persons subject to workman's compensation laws of California" <br /> f <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 re ations of the n oaqut Local Health District. <br /> t_- <br /> APPLICANT' SIGNATURE X <br /> FOR DEPARTMENT USE ONLY , <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT. ❑ PER SITE` ""❑ EACH T❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ---- - - .. <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE' CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> y- FEE <br /> LESS ^ <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> - <br /> Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - '1601 E.HAZELTON AVE.;P.O.Box 2009 STOCKTON,CA 95201 <br />