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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION, V2_/-2_[,0-S( <br /> 1 (For Non-Transferable, Revocable,-and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PER T <br /> , A JEk 'LI UID W STE <br /> Applicatio s by m!de to c sine e.juri C I area of the Sa uin oc#Llje t tric <br /> Business Name Addre <br /> aOwner dress <br /> J Firm Partners, Addresses an, h e h[UCn er % <br /> 0. Business Telephone No. _ Emergency Telepho o. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Informatln <br /> 1. 17 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For JUIy 1, June 30, 19-' - Disposal Sites.. - <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No S CAL-'L"icen`se Renewal No. ! <br /> Capacity Measures No- -. x-r- <br /> Equipment Parking Address ` 1 <br /> 2. ❑ PUMPER YARD <br /> For July 1, I June 30, 19 <br /> No. of Vehicles Stared - l <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST " <br /> R.S. or R.C.E. Name R.S.-or R.C.E.No. <br /> f -� Test 17ate/TI <br /> ") <br /> 'L.-."- — <br /> Test Location j <br /> 4. ❑ S 'NITATION PER I <br /> i <br /> Job Location + <br /> O Address <br /> PTIC TANK © CES OOL LEACHING FIELD ❑ ❑ PACKAGE PLANT n} <br /> PERMANENT ❑ TE ORARY ❑ NEW ❑ REPAIR ❑ OTHER '; e''4 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 r" t <br /> Type Construction Disposal Site <br /> No. of Units 5 Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name __ Where Certified I" <br /> Plant Location <br /> Plant Capacity <br /> p7 No. Units Served <br /> 7. ❑,LAUNDRY For�July 1, -June 30, 19 <br /> SIZE: is❑ Less,Than"'00 Sq. Ft., El Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home owneror Licensed agent's signature rmttifiesthe totrnwing:"I certffythat infite performance of the wo rk for which this permit is issued,I shall not employ any person <br /> in such manner 8 to beeomC subject to workmari s compensation lays of California.' <br /> Contractor's hiring or saRr-cm"racting-signature certifies the following: `i certify that in the performance of the Work for which this permit is issued,l shall <br /> employ persons subject•to,workman's compensation laws of California." ? <br /> t , s <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> or dinances,'state'laws,and;_rules n regulatio s of the San J quin Local Health District. <br /> APPLICANT'S SIGNATURE X' <br /> x <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 0`PEfI'SITE"- 13-EACH`---'-• January 1.8-Received-By_January 31,...E-0 July 1 8,Received By July 31 <br /> REMIT <br /> SICCING o »REMIfiTANCEr- - -�$ / <br /> i EASE EXPLANATION DATE DATE REMITTED AMOUNT CHECKED <br /> FEELESS <br /> ` PRORATION 1" ;lk ' �.'y 1 , - <br /> TM - <br /> PLUS <br /> PENALTY <br /> � S <br /> OTHER f t r _ .•� " '+a' ry ,.. I <br /> OTHER i .�i 3+ .. ;•�,. ! - <br /> Received by ? Date 'Receipt No. _Permit Nb,` s Istudnee Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH'PERMIT/SERVICES- ""`1601-v A2ELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br /> rw�_AA__4 'ti,- -V, -zf-> r z <br />