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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ' APPLICATION <br /> i (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> A' ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> to Business Name (DBA) Address — -��? �*, 8 <br /> aOwner Address - <br /> J Firm Partners, Addresses and Telephone Numbers _ <br /> no' Business Telephone No. 931-049-7� Emergency Telephone No. - <br /> Contractor Licence No. ^� <br />{ "U <br /> rd LApplicants Name (Print) � _ na :Title 8b7��1' Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> r - <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) t 4 <br /> For July 1, June 30, 19 _ Disposal Sites - <br /> Description(Make/Yr., Color) l Tn <br /> Serial No. i 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 /> t 3. ❑ PERCOLATION TEST <br /> t :R.S.or R.C.E. Name R.S. or R.C.E. No. s <br /> Test Location TestDate/Tim ,b <br /> 4. ❑ SANITATION PERMIT t <br /> 4 <br /> Job Address/Location ) <br /> Owner AdKress <br /> ❑ SEPTIC TAN ❑ CESSPO LElLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 13PERMANENT E] TEMPORARY .1 ❑ NEWREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction . Disposal Site <br /> No. of Units t 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 <br /> f No. Units Served <br /> - - <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 owner orlieensed agent's signature cat,,.ffes the foII,Wing:16ertity That in the performance of ih a work forwh ich this permit is issued,l shall not employ arty person <br /> in such manner as to become subject c wo=kman's componsation laws of California." �. <br /> Contractor's hiring or sub <br /> -corircetirg siQnatura certifies the following: 1 certify that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's 06mpensation caws of California." <br /> a <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San.Joaquin County <br /> ordinances, state laws, and ru n ula ' of the San Jo uin ocal Health District. <br /> APPLICANT'S SIGNATURE _ <br /> a 'FOR DEPARTMENT USE ONLY € ' <br /> K <br /> f Fee Is Due: 13 ANNUALLY ❑-PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31, ❑�Jruly-1 &Received By July 31 <br /> REMIT <br /> BILLING !. REMITTANCE $ AMOUNT bUE CHECKED - <br /> BASE EXPLANATION �{• - <br /> DATFT'-; ?- DATE REMITTED 7, AMOUNT <br /> _ 31 <br /> ktl <br /> FEE <br /> LESS <br /> PRORATION <br /> 4 <br /> PLUS <br /> PENALTY gyk g i <br /> y OTHER -- - - r '" - - - •' <br /> OTHER r - 7 - _v• !� _ . _ .. <br /> Received by Date 1, Receipt No. Permit No. is uance Date, Mailed Delivered <br /> APPLICANT—RETURN-ALL COPIES TO- ENVIRONMENTAL HEALTH PERMITfSERVICES 1601 E:HAZELTON AVE.,P.O.box 2009 STOGI(TON,CA 95201 <br />