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* _ Applications Will Be Processed When Submitted Prop`%ly Com_r1 Sure To Sign The Application. <br />S <br />f 4 APPLICATION <br />(For Non -Transferable, Revocable, and Suspendable) SEPTAGE <br />ENVIRONMENTAL HEALTH_ PERMIT <br />LIQUID WASTE <br />Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /># <br />,'Business Name (DBA) Address <br />z Owner Rars. Address <br />CHECKED <br />J Firm Partners, Addresses and Telephone Numbers <br />aBusiness -Telephone No. Emergency Telephone No. - <br />r <br />Contractor Licence No. <br />L Applicants Name (Print) Z Title �� n e- 7� Date <br />n <br />FEE <br />- Please check Applicable Category (1-7) and Fill In the Required Information,-" , „t..":'- � � <br />, <br />1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />For July 1, 'June 30, 19 •Disposal Sites <br />4 <br />Description (Make/Yr., Color) <br />ti Serial No. CAL. License No. CAL. License Renewal No. <br />Capacity Gal., Weights & Measures No. <br />Equipment Parking Address _ <br />PLUS <br />2. CJ PUMPER YARD <br />For July 1, June 30, 19 <br />No. of Vehicles Stored s <br />r <br />.No. of Chemical Toilets Stared '* _ <br />3. D PERCOLATION TEST — <br />- <br />R.S. or R.C.E. Name R.S. or R.C.E. No. ' 1 <br />Test Location Test Date/Time ' <br />OTHER,. <br />4. ❑ SANITATION PERMIT, <br />Job Address1Location <br />�1 <br />Owner dYl . /YI1C �� Address O i I, i im POTS (ffCr <br />[� j <br />SEPTIC TANK ❑ CESSPOOL 19 LEACHING FIELD 4 M SEEPAGE PIT i] PACKAGE -PLANT <br />� I <br />PERMANENT ❑ TEMPORARY AR NEW CEI REPAIR ❑ OTHER <br />5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br />Type Construction Disposal Site } _i <br />J <br />No. of Units Equipment Storage/Cleaning Location(s) ! } <br />Received by Dale Receipt No Permit No. Issuance Date Mailed Delivered <br />6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br />Operator Name- .Where Certified <br />Plant Location <br />Plant Capacity ENo. Units Served <br />7. ❑ LAUNDRY For July 1, - June 30, 19 ,f <br />SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft.' <br />❑ DRY CLEANING, Chemicals Used/Amount/Mo: <br />Home ownero'rticensedagenf'g63gnatttretsertifinsthefollowing: "Icertifvthalistheperformnceofthe workfor whichthis permit Isissued, ishall not employ any person <br />in -such manner as!t) become subjecl la workman's z;ori1p ensaf:a-la•:!:,,3f <br />C011traetor's hirin! or sub -contracting signature! rar4fins-144 ,Dilor. r,g: "1 c0ify that in the pertormance of the work for which this permit is issued, I shall <br />employ persons subject tu`workman's compensa►ion laws of California." <br />I hereby certify that I have prepared this appli ati nd th the work will be done in accordance with San Joaquin County <br />ordinances, state laws, and rules and _regulatio the Joaquin Local Health District. <br />APPLICANT'S SIGNATURE X <br />IG <br />Fp DEPARTMENT USE ONLY <br />Fee Is Due: El ANNUALLY _ ❑ PER UNIT ❑ PER SITE 0 EACH _ ❑ January 1 & Received By January 31 ❑ July 1 & Received By July 31 <br />REMIT <br />BASE <br />EXPLANATION <br />BILLING " REMITTANCE <br />AMOUNT DUE <br />CHECKED <br />i- DATE DATE <br />REMITTED <br />AMOUNT <br />FEE <br />C3 0 <br />4?t <br />4 <br />LESS <br />" PRORATION <br />PLUS <br />PENALTY' <br />- <br />OTHER,. <br />- <br />e OTHER <br />.. <br />I "J ?I <br />Received by Dale Receipt No Permit No. Issuance Date Mailed Delivered <br />'i -a eaom <br />