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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> .- ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application Is reby mad o rry usinep in the jurisdictional area of the San Joaquin Local Heajth Dist ' t <br /> OF Business Name (DBA) A ess�� `'`-�► ' <br /> aOwnertT a y��( Address <br /> L) Firm Partners, Addresses and Telephone Numbers <br /> EL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date Z Z— <br /> Please check Applicable Category(1-7)and ill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) f <br /> For July 1, June 30, 19 Disposal Sites 11 <br /> Description(Make/Yr., Color) r' <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. SANITATION PERMIT <br /> Job Address/Location µ' —e k—f (f <br /> Owner - z- t ; I ca Address <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW REPAIR ❑ OTHER <br /> ❑ CHEMICAL TOILETS For July 1, -Ene 30, 19 <br /> Type Construction Disposal Site f� <br /> No, of Units _ Equipment Storage/Cleaning Location(s) <br /> f. ❑ 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/Amount/Mo. <br /> in MS such anp.er lscensedrrgant'scttowreaertHiBattlefoil <br /> owing:"Icertify that in the performance of the werkfdrwhich this permitisissued.I$!i1elemplpy;nyperstin <br /> in such manner as to become subject to xrorkMarl'S compransa#iofl laws of Gafifcttlia." <br /> CeneracWr's hiring or;sub-crmraeting si9vature certifies rna joHawirlg: -{I entity that in the performance of the work for which this peQ,t shall <br /> employ Persons subject to workman's compensation laws of Califortlia." <br /> 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 an re lations of the San Joaquin L al Heal District. <br /> APPLICANT'S SIGNATURE a <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 EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE c £ <br /> LESS <br /> PRORATION <br /> i <br /> PLUS <br /> PENALTY <br /> w <br /> OTHER <br /> OTHER <br /> d>o�O . <br /> Received by bate Receipt No. Permit No. seance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.D.Bos 2009 STOCKTON,CA 95201 <br /> �l <br />