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Applications Will Be Processed When Submitted Properlyrompleted. Be Sure To Sign The Application. <br /> APPLICATI N <br /> (For Non-Transferable, Revocabldljancl Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby ma a to carry on business in the jurisdictional area of the Joa uin Local Health District <br /> H Business Name (DBA) T!3 TRfL Address -. .� .. 091WILele-► <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers — f <br /> aBusiness Telephone No. — a4p 1 ZP Emergency Telephone No., <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information f <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRAYION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites 7 <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 /> Test Location Test Date/Time A <br /> 4, SANITATION PERMIT �- <br /> Job Address/ cation /W-5/3 <br /> Owner __ __ � Is&ln '�offl: Address <br /> M SEPTIC TANK ❑ CESSPOOL ZQ LEACHING FIELD I] SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER W <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 W <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 /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served a <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 owneror liaerrsed agent's signature certifiesthe foltowint3:"l certify that in the performawmeof the Work for which this permit Is issued.I shall rrot employ any person <br /> in such manner as to become subject to workman's compensation taws o,California." <br /> Contractor's hiring or sub-contracting signature certifies the foilavArg: "I certify that in the performance of tf re work for which this permit is issued,I shall <br /> employ persons subject to workman's compensation laws of CatiforAia" <br /> I hereby certify that I have prepared this application that a work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulatio f San quin Local Health District. _ <br /> 1' <br /> APPLICANT'S SIGNATURE X "�— `eY ` <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 /> _ <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE L4S �O <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY • <br /> OTHER <br /> OTHER Q <br /> Received by Date Receipt No. Permit No. Issue ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM n rYsERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 . <br />