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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 /> i LIQUID WASTE <br /> Application is hereby made to carry on business in he jurisdictional area of the San Joaquin Local Health District <br /> Mr-Business Name (DBA) n - ��1oq_R J S� /IF '�V� Address • �..X � � <br /> z Owner Rd <br /> dress <br /> a „ <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. Ef66 704 0 7 Emergency Telephone No.. <br /> Contractor Licence No. <br /> L Applicants Name (Print) 6Z Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Into alion , x <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July.1;- June 30, 19 Disposal Sites — - - - - <br /> � y <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. I <br /> Capacity Gal.,Weights & Measures No. ' <br /> Equipment Parking Address-N� ^� <br /> 2. ❑ PUMPER YARD <br /> For July 1, ` June 30, 19 <br /> k <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. IS SANITATION PERMITa <br /> Job Address/Location _7,1X, A914, 411A II&D' <br /> Owner �91 - .9L"Ve Add r4ss <br /> J9 SEPTIC TANK ❑ CESSPOOL R LEACHING FIELD K SEEPAGE PIT ❑ PACKAGE PLANT 4 <br /> )I PERMANENT ❑ TEMPORARY )Q 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 <br /> _ __ �_ Where Certified <br /> Plant Location f <br /> Plant Capacity __ <br /> No. Units Served 1 <br /> a 7. 11 LAUNDRY ' For July 1, -June 30, 19 Q <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ Dl;Yr4l WWa I al U ed/Amount/Mo. t <br /> �at nn 'e t�nlalureceh+'fiesthef011pyrring!ACertifythatintheperformaaaeeoftheworkforwhichthispermitis[$sued,Ishallnotemp(8yartyperson <br /> In SIIG#1 andntter 83 In became sul OCf.lb,tWkI1101�S com cn5�tip a latt5 tff CaiitOrnia. <br /> Gantrdetot"Iso hirings 30) or aub•pnan's int± Olpa}�tt.,.o Marti;,, t;t� o�#�vriny; t certify that iia the performance of the Mork for which this permit is issued,!shat{ <br /> employ persons sub)>}ct to workman's eamper,satia,a taw at Laii;arnia." } <br /> I hereby certify that I have prepared this`application and that'We work will-be d?)""• accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the Sa aqui Local Hea ri ` c <br /> APPLICANT'S SIGNATURE X j <br /> i <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 /> f <br /> FEE .. - <br /> LESS <br /> + PRORATION...e.�... <br /> PLUS <br /> PENALTY <br /> IV <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit N IssLiance Date; Mailed Delivered <br /> "'APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON!1 .Box 2009 STOCKTON,CA 95201 <br />