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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 /> s: LIQUID WASTE _ w <br /> Appl ica • n i he by made tQ c(rry\on bus' ess in the' risdic_tional area of n aquin Local Health Di <br /> y Business Name '15 _Address' ~� <br /> aOwner - . T Address <br /> Firm Partners, Addresses a'nd Telephone Njjtubers' <br /> M Business Telephone No.; �� - A _ Emergency Telephone No. <br /> Contractor Licence No. rr!! <br /> '1 <br /> L Applicants Name (Print) i.!�� _ -Title'#A 44.lb-4r .�� Date <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(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal ,Weights&Measures No. t <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD 1 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑`-PE <br /> RCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. filo. <br /> Tes cation Test Date/Time <br /> 4. SANITATION PERMIT `�'Ilk- <br /> 92A <br /> Jab Addr s/Location <br /> §kn er ��Yr�f-L'�� Address <br /> EPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT tJV <br /> ERMANENT ❑ TEMPORARY El NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June*0, 19 � _ <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) " <br /> S. 0 PACKAGE TREATMENT PLANT 1For July 1; -June 30, 19 <br /> Operator Name r :� "` ' Where Certified <br /> Plant Location _ <br /> Plant Capacity v ' No. Units Served <br /> 7. ❑ LAUNDRY For July 1 '`June 30,,819 _ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft:',NO Mo'fe Than 1,000 Sq. Ft. i <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo t' } <br /> Home owner orlicenssdAgent'ssignaturecart ffierrtllefoltm"mina:"I r..erfify#has iliih-9 performance of the work forwhich this permit is issued,I shall not employ any person <br /> In such marine:as to bac3me subject to wotkman's cnlrspensafian lavfr.of Caiitoroia" <br /> Contractor's hiring or sub-contracting ;Igna z:re--t2r3flias 7? 'iallowinc; 'S seri fy;;hat in the performa^e.of the work!or which this permit is'tssuetl;I shall <br /> em&y persons subjeci to vaorklra s�013?IhEi15atiE31!13W5 Of Iiiltli}CtiiF:.' w <br /> I hereby certify that I ha prepared this applicatio and that the work will-be done in accordance with San'Joaquin County <br /> ordinances, state laws n r reg ions o San Jo uin Local ealth District. c <br /> APPLICANT'S SIGNATURE <br /> t 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 /> Bi REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION _ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE . .7 tip. <br /> LESS <br /> 'PRORATION <br /> PLUS 1 <br /> • 'PENALTY - <br /> `OTHER <br /> OTHER <br /> Received by Date Receipt No..-: Permit No. I*uanc#Pate ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ' <br />