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Applications Will Be Processed When Submitted Properly Completed. BeSureTo SignTneAppucatlon. <br /> APPLICATION <br /> t (For Non-Transferable;Revocable, and Suspendable) 1 SEPTAGE <br /> .. ENVIRONMENTALr HEALTH PERMIT <br /> LIQUID WASTE <br /> - r <br /> Application is hereby made to carry on business in the jurisdictional area of.the San Joaquin Local Health District + <br />/'tn Business Name (DBA) ( Address` <br /> r S Address r <br /> a Owner <br /> Firm Partners, Addresses andTelephoneNumbers <br /> a Business Telephone No. Emergency Telephone-No. <br /> Contractor Licence No. y ~ �:y ��F 5 � Y _ �?(/fl/ Date <br /> Applicants Name (Print)T/�'I�=CjL-(_ -Title i - .�, <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. Cl PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, - ' - June 30,-19 Disposal Sites <br /> -- - <br /> 1 ' <br /> Description(Make/Yr., Color) CAL. License Renewal No. '--` <br /> Serial No, <br /> I CAL. License No. Q; <br /> Capacity Gal.,Weights & Measures No. r- <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored I <br /> No. of Chemical Toilets Stored I� <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name 0 <br /> r Test Date/Time W <br /> Test Location <br /> 4. 11 SANITATION PERM O� t�� � � _ �' <br /> Job Address/Location -" a� K <br /> Address <br /> Owner <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 11SEEPAGE 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 Where Certified <br /> ps Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served - f <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 - <br /> ❑ re a <br /> SIZE: C3 Less Than 1,000 Sq. Ft., (Mo Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo- <br /> i <br /> sed/Amount/Mo. d r <br /> komeownerorlioertsedagent'ssignaturecerti4?@St' 'frsllO+wing:'Icertiifythatirl4heperiarms.ce()Itheuorl:forwhichthispermitisissued,Ishallnotemployanyperson 1 <br /> in sncll manner as to bscosne subject to workr751i s ccmgetlsatipn laws a.E alifnrr+a ' f <br /> Contractor's hiring or sub-contracting signntury ce!1i`res sllc fotlu+aing: "I certify that in the per.lo.rnlant a at the work for which this permit is issued,l shalt <br /> I employ persons subject to workman's colnpeilsatlon laws of California." (' <br /> I hereby certify that I have prepared this application and that the work will be-done in accordance with San Joaquin County Y <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> I <br /> APPLICANT'S SIGNATURE X <br /> 1 t FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ,❑ PER SITE ❑ EACH 1❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITJuly 31 <br /> ~BILLING, REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> ' FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> _ PENALTY �- /} <br /> OTHER 17 <br /> i r! <br /> OTHER <br /> Date eceipt No. Permit No. Issuance Date Mailed Delivered <br /> Received b ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES <br /> 1601 E.-HAZEITON AVE:,P.O.Bo=2099 STOCKTON,CA 95201 <br /> k. <br />