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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. k <br /> APPLICATION <br /> ' Y (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> k <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin-Local.He_alth District. �- <br /> ,n Business Name (DBA) ,Address . <br /> c Owner �� t�$��� tib c '— Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> M Business Telephone No. Emergency Telephone No. <br /> s Contractor Licence No. r u <br /> L Applicants Name (Print) Title?i - _ Date- } <br /> Please check Applicable Category(1-7),and Fill in the Required,lnformation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)- <br /> :For Jufy'1; . ­�. -"June 30;19- Disposal-Sites. _ <br /> Description(Make/Yr., Color) . <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal-,-Weights-&-Measures-No. <br /> Equipment Parking Address ! <br /> f 2. ❑ PUMPER YARD <br /> I For July 1, June'30, 19 fi <br /> No. of Vehicles Stored <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 /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT r <br /> 4. <br /> Job Address/Location <br /> Owner_s7k. 10 Address <br /> 11SEPTIC TANK 13CES POOL E] LEACHING FIELD -❑ SEEPAGE°PI ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR 2rOTHER aba�t�do r s@��/C- <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 r I <br /> ' Type Construction' }' 1, Disposal Site ' <br /> No. of Units ( Equipment Storage/Cleaning Loca'tion(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 1 <br /> Operator Name # Where Certified- <br /> �r <br /> Plant Location <br /> Plant Capacity t No. Units Se-rved, <br /> 7. ❑ LAUNDRY For July 1., -June 30, 19 - . <br /> SIZE: .❑ Less Than 1,000 Sq:Ft., More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. { <br /> in such wrterarliaaneedsg�nYssianetureiartiflaatt:�tallowir�;"!cariify1haf;ntY!ep2rformarceofthry orkfar�,•hichthis <br /> in such manner as to hec:blre Sub;ect to vrcrkr:,;s s•tsm ensatjoll l yIs of C_,;crnia 1 permit isissued,l;fiall nr�tompfoyanypersorl <br /> i Contraetnr's h+ring ar-gutticontracti 1g F,�r»;,rc czrtsf:�s the `oliowing: ;'I certiiy that In the perioP riarice of iiie work for whicft this permit is issued,l shall <br /> emplay persons subject to workman's compaiisation laths of Caijtarnia" <br /> l �t <br /> I hereby certify that I: ha prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws n rules andr gulatio f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATUR f <br /> _. <br /> FOR-DEPARTMENT_.USE�ONLY <br /> . <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 37 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING. REMITTANCE . $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTEDAMDUN7 <br /> FEE r /' <br /> I LESS <br /> PRORATION <br /> PLUS ' <br /> PENALTY r <br /> i OTHER <br /> OTHER <br /> t. <br /> i4� 0 - } <br /> Received by , I Date 'Receipt No! Permit,No- ,i• . Issuance Date Mailed <br /> Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTACHEALTH PERMIT/SERVICES _ 1601 E.HAZELTON AYE.,P.O.Box 2609 STOCKTON,CA 95201 - . <br />