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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> a — " - APPLICATION <br /> (For Non-Transterable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT 1 <br /> LIQUID WASTE r <br /> Application is hereby made to carry on business In the ur'sdictional area of t an quip L�°�aI H Ith Distri <br /> Business Name (DBA} L_F �,_ L` � I+C�(L Address . �1.. L �'�J-1 Q lei, <br /> z Owner E . W i L L Address <br /> a <br /> Firm Partners, Addresses a l; phone Numbe s <br /> aBusiness Telephone No. 5 f� Emergency Telephone No. <br /> Contractor Licence No. . _ il . <br /> Dii <br /> L Applicants Name (Print) )i:NW1A_ Title <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 <br /> Description(MakeNi Color) <br /> Serial No. CAL. License No. ___ CAL. License Renewal NO. I <br /> Capacity Gal.,Weights&Measures No. - <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vphicles 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 PERJob <br /> Job Add ss Location _ <br /> Owner Address Vy\ 1 <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY n 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 _ Q -- 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 /> ❑ D��{{Y CLEANING., Che ical ,U d/Amoun o <br /> #iomeowW rTaercse�agee�t1ssgnetureix stFlelralli <br /> in such manner as to beeome subject t0 workmart5 wmpensattorl taws M Ca ifOrnla= a <br /> contraetbr's hiring or "&coirrtractfnq sigrmture cerdf`ms rile fanowing. "1 certify that In the performance of the work for which this permit is issued,I shall <br /> employ petsons subject to workman's compensation Dews of California." <br /> hereby-ce irtify-AhAl-L have prepared t I ap lication ar \that the work will be done in accordance with San Joaquin County- <br /> ordinances,, state laws, n es ydr, he San Joacili Local Health District. -� <br /> APPLICANT'S SIGNATOR <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 REMITTANCEkREMITTED <br /> $ <br /> 8A$E EXPLANATION DATE DATE AMOUNT DUE CHECKED i <br /> AMOUNT <br /> FEE a <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY / <br /> s <br /> OTHER / <br /> OTHER <br /> Receive byReceip[No. Permit No. . issuance Date Mailed Delivered <br /> APPLICANTRETURN ALL r____1 O: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />