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i Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> _Application s y mad o afv�'. siness in the jurisdictional area of the San Joaquin Local Health Districts s <br /> n y <br /> N Business Na BA) Address 506�C22 �Z 7' <br /> z Owner - Address �� f„ - <br /> Firm Partners, Addresses an Telephone Numbers <br /> aBusiness Telephone No. << Emergency Telephone No. „- <br /> _J Contractor Licence No. - <br /> Applicants Name (Print] <br /> J Title 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 30,09 f.:. _.Disposal <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. ”-KCAL. 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 /> l No. of Vehicles Stored- <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST i <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test`Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT �._. .#- <br /> Job Address/Lecation w e <br /> Owner - - ddress <br />! r6EPTIC TANK. ❑ CESSPOOL } ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLA<T <br /> ❑ PERMANENT © TEMPORARY ❑ NEW ,/REPAIR ❑ OTHER <br /> CHEMICAL TOILETS For July}T,-June 30, 19 <br /> Type Construction.- Disposal Site t <br /> No. of Units ' Equipment Storage/Cleaning Locations) <br /> 6. © PACKAGE TREATMENT PLANT For July 1,-June 30, 19 F <br /> Operator Name Where Certified t <br /> Plant Location <br /> T r No. Units Served A <br />( -Plant Capacity - � - . <br /> 7. ❑ LAUNDRY For July.1, -June 30,.19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,' ❑ More Than 1,000 Sq. Ft. e <br /> ❑YDRY CLEANING, Chemicals Used/Amount/Mo. <br /> } <br /> Home owArorlieansedagant'4s!gnclture eertifit"tThe Mrlo:vinw."!rertifyfhatiii the perf•:iman're of thcwbrk forwhich this permit is issued,l shall not employ any person <br /> in such manner as to becomebject ib;w'otk,^ .r:'s c�:t:oe;s tis;1 l `r_,: <br /> s+o <br /> ` Contractor's hiring or sub-contrdctirrts ^JgnL'Jra Cci,:ii 1 - fatiovving;'- I cei'ti'y that is the perfotmance of the work torwhich this permit is issur 'hall <br /> employ persons subject to workmaris'compe,-lsatiotT layrs ci CaliSornia:' <br /> hereby certify that I have'' ed ation a d that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a rules n r la ions of t San Jo q in Local Health District. i <br /> 'APPLICANT'S SIGNATURE X <br /> -FOA DEPARTMENT-USE ONLY <br /> Fee I8 Due: ❑ ANNUALLY-' ❑ PER UNIT, ❑ PER SITE ❑ EACH ❑ January 1-&Received By January 31" ❑ July i &'.Received By July 31 <br /> I <br /> REMIT <br /> BILLING REMITTANCE �$ <br /> _ e AMOUNT DUE BASE EXPLANATION -r PATE _ DATE _ „REMITTED AMOUNT <br /> D <br /> CIIJ <br /> x FEE _. �f�_ <br /> LESS <br /> PRORATION- <br /> PLUS <br /> PENAt_TY - - <br /> I'. OTHER <br /> �. <br /> OTHER : <br /> Received.by Date -1 :Receipt No: Permit No. ISSuanc Date _ Mailed Delivered <br /> - <br /> APPLICANT=RETURN ALL COPIES TO:" 'ENVIRONMENTAL HEALTH PERMiTlSERYICES' - - `1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />