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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 l.Qreby mad fo carryon' usiness in Padjurisdictional area f the San Joaquin Local Healqrrl�istrict <br /> FBusiness Name (DBA) 1't'yLLa C C'��� ./�. _ .. e_ All <br /> a Owner Address <br /> J Firm Partners, Addresses and elephone Numbers <br /> Q.a Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No, v., <br /> Applicants Name (Print) , _ s-/+I" Title - i f= Date- <br /> Please check Applicable Category (1-7)and Fill n the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 0i <br /> For July 1, June 30, 19 - - Disposal Sites <br /> Description(Make/Yr.. Color) <br /> Serial No. -"` CAL:License No. � _ "— ' 7"GA12.License Renewal No. <br /> Capacity Gal.,Wei hts & Measures No. <br /> Equipment ` ' `f"` •�,`. <br /> Parking Address ' <br /> Y2. O'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. flame R.S.or R.C.E. No. <br /> Test Location — - -- - Test Date/Time - 1 <br /> 4. SANITATION PERMIT <br /> Job Address/Loca na <br /> Owner e' a Address <br /> JSEPTIC TANK ❑ CESSPOOL Uk-EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLAN' <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR BOTHER 5UJ4 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 1 <br /> Type Construction Disposal Site <br /> ` No. of Units Equipment Storage/Cleaning Location(s) - t <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 17'— rn <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 /> Home owneror11censedagent's signFturecerlifiesthe fatlowling:"I certify that in the performance of the workforwhichthis iirmitisissued,Ishall"Iemployanyperson <br /> in sLti h manner as to become subteci to workman's compnnsatian lams of Calitarnia." r <br /> Contrticlor's hiring or sub-contracting sup:•;aturc caa-ri;?es ft. ;ettcwi:.r; `I eertity that in the p e;formance of!he vlork for which this permit is issued,l shad <br /> en pi0?persons sr hjec#to`:orkrt<�i s eo 111.n.stti.,i:F;'.S Cf%alilomia." u 7r I � - <br /> I hereby certify that I have pre.a,fed this application and that th r i be done in accordance with San Joaquin County <br /> ordinances, state laws, and r es a alio of the n Joa uin oca trict. <br /> t <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY # # t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 , <br /> BILLING REMITTANCE $ REMIT <br /> ' <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE -- <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> ' OTHER <br /> OTHER r •"~ �- <br /> Received by Dat4 Receipt No. - ,� Permit No i:r Itsuance Date Mailed Delivered I <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />