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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE �4 <br /> Application is hereby made to carry on business in the jurisdictional.area of the San Joaquin Local Health District. <br /> Business Name (DBA) -Addre-s - n <br /> i a Owner._Arh - 1$F�"/7-� -- ti;. Address_115� 11116 <br /> it J Firm Partners, Addresses and Telephone Numbers <br /> i a Business Telephone_ No, Emergency Telephone No. <br /> t � y <br /> 1 LQ Confractor Licence No. <br /> 'Applicants Name (Print) Title Date <br /> Please check Applicable Category 1-7 and Fill in the Required Information p� <br /> PP 9 ry( 4 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) �} <br /> For July 1, - June 30, 19 = - Disposal Sites t <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No.. = CAL. License Renewal No. 1 <br /> Capacity t Gal.,Weights & Measures No. <br /> Equipment Parking Address. <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 "s �� •. <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 ' <br /> 4. ❑ SANITATION PERMIT i <br /> Job Address/Location <br /> I <br /> Owner" Address $� <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPACPP11,T­J1J­PACKAGyEPLANTww' w"� ,��❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIOTHER ooAraiv <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 <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19.- <br /> SIZE: <br /> 0, 19.SIZE: © Less Than 1,000 Sq. Ft.,, ❑ More Than 1,000 Sq. Ft. { <br /> ❑ DRY CLEANING, Chemicals Used/ <br /> How owmior licensedagenVe signaturacerttfieathefollowfng:"f certifyy that�-i ltte work ferwhteb this permit is issued,l shalt riot employ any person <br /> in such manner as to become suhiect to workman's compensation laws of Califorstia.' <br /> Contractor's hiArlig-or-sub•-contractlttg signature eertifma the following'•'-f certify that iR the periormance of the work for which this permil is issued,I shall <br /> employ persons subject to woAmarl's compensation laws of California." <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, a=-rd regulations of the an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X� c - <br /> -' -- <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 /> BILLING REMITTANCE $ REMIT <br /> BASE_ EXPLANATION DATE DATE REMITTED <br /> AMOUNT DUE CHECKED <br /> B <br /> AMOU <br /> FEE orw— <br /> LESS <br /> PRORATION k W <br /> PLUS 7/ ' <br /> PENALTY - - <br /> OTHER <br /> OTHER <br /> Received - Date :Receipt No. Permit No. f { Issuance Date - Mailed Delivered <br /> APPLI NT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTON AVE.,P.D.Box-2009' STOCKTON,CA 95201 - <br /> 7 <br />