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Applications Will Be Processed WhenSubmittedPropertyGompieteu. vc ou— .....y • ••• - ��•• <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUIO WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> i <br /> wBusiness Name (DBA) Address <br /> z Owner Address <br /> a <br /> L) Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) - <br /> Title Tri ""'t Date <br /> Please check Applicabld'Category (1-7)and Fill-in the Required IMormation <br /> 1. ❑ PUMPER VEHICLE PERM FT"F1EGiSTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) r ` <br /> CAL. License Renewal No. <br /> Serial No. CAL. License No. f <br /> fl <br /> Capacity; Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD r��y� <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST i <br /> R.S. or RICE. Name R.S. or R.C.E.No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT 2L <br /> Job Address/Location J 5 5 r <br /> Owner - Address � <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 13 SEEPAGE PIT 13 PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR 0 OTHER <br /> 5, ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Loc <br /> atioh(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> - Where Certified <br /> Operator Name --- <br /> Plant Location <br /> No. Units Served <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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. -, <br /> Horne ownerorlicemwdagent'"�IgnshVraPsr4"1*1xefnllowinu:"I rertify1hatintheperformanceofttsawarkfokwhrchEhlsteFrlliiisiE'ler,isha:1Intczplovany er^'" <br /> I <br /> in such mariner as to becurn^s-i"lact to war:;^�r,'s c.l c-<''.ron'aws at Cafifutltia„;certify that in the performance nt t'c vrcrk fer rf 3ch t11. ;sar:pit d,I <br /> Cgeitraeter's hirinq or s1�r-Cnratrc^a:rtg r.:.ir..;'.i;.. rti:ies 111b f4fie1Niltg <br /> elnptoy persons subject to wurkrklali s WR111U115"ii la>tis of Caiifofnia.' �� <br /> 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 an regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X _ <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 /> BASE EXPLANATION BILLING REMITTANCE '$ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> PRORATION–= --` <br /> PLUS <br /> PENALTY <br /> r <br /> OTHER JJ+ <br /> OTHER <br /> r y ^� Date Receipt Na Permit No. I ance D to Mailed Delivered <br /> Received by <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />