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r Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Apg);cation. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> �- *- LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> NBusiness Name (DBA) Address <br /> i Owner Address <br /> a - u <br /> J Firm Partners, Addresses and Telephone Numbers ` <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> a <br /> I LApplicants Name (Print) Title .r - Dale <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> F 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, ... June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <7' <br /> Serial No. CAL. License No. _CAL License Renewal No.. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address. <br /> 2. ❑ PUMPER YARD y K ~ <br /> For July 1, June 30, 19 <br /> ' No. of Vehicles Stored 4 -( � '' T <br /> No. of Chemical Toilets Stored - k <br /> 3. 0•PERCOLATION TEST i <br /> R.S)or R.C.E. Name R.S. or R.C.E. No. <br /> Test;Location ' ' } Test Date/Time a <br /> 4. 0 $A'Ni1 'rl'bN PERMIT <br /> Job Address/Location <br /> Owner j Address` <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD --❑,SEEPAGE PIT ❑ PACKAGE PLANT ` <br /> ,❑ PERMANENT ❑ TEMPORARY j„ ❑ NEW ❑ REPAIR'S ❑ OTHER <br /> 5 #❑ CHEMICAL T. (LETS ..For July 1 Jur1e:30, 19 ; <br /> ,Ty pe.Co,*ruction �' '" C _Disposal Site ., <br /> - ,No:of Units a _ '�»•- •t <Er;uipmentrStorage/Cleaning.Location(s) <br /> a <br /> 6. <br /> �,❑"PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> li <br /> =Operator Name � -.Where Certified <br /> • y <br /> , r <br /> Plant Location <br /> Plant Capacity a= No. Units Served r �# <br /> { 7. ❑ LAUNDRY.- For July 1, -June 30,.19 ` <br /> SIZE: .0 Less.Than=1,000 Sq.'FtY ❑ fvtore.Than 1;000,Sq_ Ft. <br /> t .,;. A <br /> ❑ DRY CLEANING, Chemicals Used/Amourit/Mo.} Ll r <br /> ' dome ownetorlicensedagent'.s signature certWcstl` foftowing:"I rertily that io lhexrfl3rr rance of the work for which this permit is issued,l shall not employ any per;;, <br /> in such rnaRner as to became subject to urarf:m..1i:�.:nn;;�elr5atio1l fasis of Calitorr:itia�� ( <br /> Contractor's hiring or sub-contracting signature certifies the following-."'I certify that in the performance at th'e wank for which this permit is issued,I shall <br /> employ persons subject to workman's compensation laws of California:' <br /> i 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 regulations of the San',JoagGin'Local Health District.. r <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE'0 # <br /> — --. - ? <br /> Fee,Is Due: 13ANNUALLY [IPER UNIT EYPER SITE 11EACH F❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> " - -t- REMIT <br /> BASE -EXPLANATIONS, BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> NL DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS ' <br /> PRORATION 4N <br /> PLUS <br /> PENALTY - -- --- <br /> OTHER <br /> r OTHER z- C ♦" �.. i- , y <br /> Received by Date Receipt No. Permit NP. _ Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.Q.Sox 2009 STOCKTON,CA 95201 <br />