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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> n. (For Non=Transferable,Revocable,and Suspendable) SEPTAGF <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> b i - <br /> ''- AppliCat `is h"ereby•rh 'd�,to car on bu iness in he jurisdictional area of the n Joa in Local Health Dist ict r <br /> 6 / <br /> �Busines ame (DBA) Address <br /> 71 <br /> z Owner 9 <br /> m .w Address <br /> Firm Partners, Addresses and Tele hone_umbers <br /> a. Business Telephone No. ". S ��� �cYk YEmergency Telephone No. <br /> Contractor Licence No. 7—7—co <br /> Applicants Name (P�rinyJr Title Date <br /> ' r..r r' k <br /> Please check Applicable°C egory(1-7) and Fill in the Required Information rk t rr <br /> 1. ❑ PUMP�ER,VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, .'.'June 30;. 9 Disposal Sites - <br /> DescriptioW(Make/Yr., Color) <br /> Serial No. r t t V CAL. License No. CAL. License Renewal No.— <br /> Ca pac ity <br /> o.Capacity -Gal.,Weights & Measures No. <br /> Equipme%. rkg-Addfess <br /> 2. <br /> 0.`P U L ..1 1. , - � <br /> MPER YARD ; it <br /> For July 1, June 30, 19 E i <br /> No. of Vehicles Stored ' <br /> No. of Chemical Toilets Stored F <br /> 3. ❑ PERCOLATION TEST t ; <br /> R.S. or R.C.E. Name `r-' R.S. or R.C.E.No. # <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Addre /L ati 2& <br /> + { <br /> Owner Address ' v <br /> ❑ SEPTIC TANK ❑ CESSPOOL..-_�CEACHING-F..IEL.C)...-.Lq'SEEPAGE PIT ❑ PACKAGE PLANT- <br /> 91PERMANENT ❑ TEMPORAI4Y ❑'NEW 6"EPAIR ❑ OTHER ��-- <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> AZ <br /> Type Construction '`,.r• -+ Disposal Site t <br /> No. of Units f '. Equipment Storage/Cleaning Location(s) # ' <br /> r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,=June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location - <br /> Plant Capacity t j � - J ° No: Units Served ` <br /> 7. ❑ LAUNDRY For JulyL1, -JuneI30,lyd , -. <br /> SIZE! ❑ Less Than 1,000.Sq. Ft.,! ❑l:More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/AmOU t/n Mo. ; <br /> HomnownerorficertseQegeni'ssignaturecertif4sthefo!towing:"Icertif thatintheperformanceoftheworkfOrwhichthispermitisissued,Ishaltnotempioyany pIt�n <br /> in such manner as to became subject to wcrkma_n's cornpensalior.•laws of California."" 4 <br /> contractor's !tiring or sub- titi <br /> 'ontracting zignsturt Cereethe•fallowing: "'I certify that in the performance of the work for which this permit is issued,I stralI r„q t <br /> employ persons subject to workman's compensation lays of California.- <br /> I hereby certify that I'liave prepa-Fled'this appilcatlon and-that the work will be done in accordance with San Joaquin County r <br /> ordinances, state,-laws, an rules and r ula 'ons of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE3X �t I; <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 JUI9_31 <br /> REMIT-' �, } <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> y DATE DATE - REMITTED 'AMOUNT'? <br /> "9 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS Y <br /> PENALTY <br /> , 1 <br /> OTHER -' I <br /> e � <br /> OTHER _ I <br /> Received by Date Receipt No. Permit No. I nuance orate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTON AVE.,P.O.Box 2D09 STOCKTON,CA 95201 - <br />