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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> i <br /> / APPLICATION <br /> i (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> . r . ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> m Business Name (DBA.) knal�e{2 _ Address <br /> - <br /> z Owner _� Address <br /> Firm Partners, Addresses and elephone Numbers <br /> K Business Telephone No. s" ato Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> Applicants Name (Print) &zn►.,i2&P 2 Title CS_? / " 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) cam' <br /> Serial No. CAL. License No. CAL. License Renewal No. <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. ❑ 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. W SANITATION PERMIT <br /> Job Address/Location <br /> Owner R—S k 2 61M 1.0 Address 5la7 4 6 /S <br /> ❑ SEPTIC TANK ❑ CESSPOOL ® LEACHING FIELD ® SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction 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 Where Certified <br /> Plant Location <br /> Plant Capacity - No. Units Served <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/Arriount/Mo. <br /> Home owner or licensed agent's "Ecertifyth tIntheperfermanceoftheworkfnrwhichthispermitisissued,Ishallnotemployanypers,- <br /> in such manner as to become sub;ect f �orkllTan;e: r:ner,.r.,tir,=lav, of <br /> Contractor's hiring or sub-contracting signature 111e +--3lorwitld: 'f certify that in the performance of the work forwhich this permit is:35aed,Is"-;: <br /> employ persons subject lo workman's compensation lawsbf California." <br /> I hereby certify that I have prepared this application and that t e work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulati San Jodrquin Local Health Dist 'Ct., <br /> APPLICANT'S SIGNATURE X <br /> b3 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATIONBILLING <br /> DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> � <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 '71- <br /> Received by Date Receipt No. Permit No. Iss ance Datel Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 99201 <br />