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LILJ JAN 2 Ap�ngons a Processed When Submitted Property Completed. Be Sure To Sign The Application. Y _ <br /> tv �� JJ � { APPLICATION <br /> t (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> SAN JOAQUIN LOCAL ENVIRONMENTAL HEALTH'PERMIT <br /> HEALTH DISTRICT LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of th San Joaquin Local Health District, <br /> rn Business Name (DBA) <br /> z Owner - <br />� 1 Firm Partners, Addresses a�Tefp�hoyN,,�umers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L AOplicants Name (Print) ! hi` /= Title ' `= <br /> - Date , -_ - <br /> Please check Applicable Category (1-7)and Fill in the Required,lnlormation <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.-- - } - <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 /> r <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT C <br /> Job Address/Location o <br /> Owner — <br /> A ress <br /> SEPTIC TANK ❑ CESSPOOL- LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT. <br />., �❑ ERMANENT ❑ TEMPORARY 0,NEW.. r. ❑,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 /> - i <br /> Operator Name - - Where Certified <br /> J <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 /> Harnaownerorlicansedagont'ssignature ceftifiestfte following.1 Certify tfiat in the perfermznce.of the warp for which this permit is issued:l sfaa€l not employ any pnrson <br /> in such manner.as to Become subject to workman's compensation laws of Cali#o1 <br /> Contractors hiring..or sub-contractirmj slgnatum'ceff flos the foll wing:E::f-cerfiiy that.in the performance of the work for whirb this permit is iVT <br /> ssued,.1 sflalt. ' <br /> employ persons subject to workman's compensation laws of CaMorn a." , � . - y <br /> r i <br /> I hereby certify that I have prepared this applicatioh.and that"the,.work will be done in accordance with San-Joaquin County <br /> ordinances, state laws, and les and gulations of theyx, n JoaquinLocal Health District- <br /> APPLICANT'S SIGNATURE.. t# <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 /> BASE EXPLANATION ' BILLING REMITTANCE $ I <br /> - _ DATE DATE REMITTED AMOUNT DUE CHECKED , <br /> AMOUNT <br /> FEE -. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY /ff. <br /> OTHER <br /> _ <br /> OTHER <br /> r <br /> trd 7 <br /> Received by Date Receipt No. Permit No. Issuance Date Maitetl Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Boli 2009 STOCKTON,CA 95201 <br /> p�► - <br />