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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APFUCAION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application 's hereby madto carry on business'n the jurisdictional area of the an Joaquin Local Health District <br /> IFS Address /L,' <br /> OF Business Name (DBA) <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. �b6 �� 7 Emergency Telephone No. <br /> a Contractor Licence No. "' -- --. - <br /> LApplicants Name (Print) Title _ � Dale 9"ZO`GZ 4 <br /> Please check Applicable Category (1-7)and Fill in the equired Information Cn <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Calor) <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 <br /> 4. OU SANITATION PERMIT <br /> Job Address/Location -�z /�m►�-?J��F �L <br /> OwnerAddress _ W <br /> Vf SEPTIC TANK ❑ CESSPOOL LEACHING FIELD OfSEEPAGE PIT ❑ PACKAGE PLANT <br /> 09 PERMANENT ❑ TEMPORARY Od NEW ❑.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 /> Operator Name Where Certified <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 /> Rome owner or licensed agent's signature eer0lfiasth*±falloWin17,:.'1 certify tl;Pi ill the nerfntinoncetrf the work for rMirh this permit is issued.)shall not employ any person <br /> in such manner as to beconm,:uble;a 10:verkma n"s•.�^,1 r, ng.tier,i r1 s nt n: :,a <br /> Contractor's hiring or suh-co.^tra^tihy signatura certifi2s -he {01.ovvfna. I r{;rtlfv thflt ill the performance v[the%vrrk for which this permit is issued,I shall <br /> employ parsons subject to workman's ccrnpertsation laws of Caliiorttia." <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 rules and regulations a San Joagkxin Local Health District, <br /> APPLICANT'S SIGNATURE X 4P101 <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEEq IS <br /> LESS <br /> PRORATION <br /> PWS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SER ES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 85201 <br />