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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> *2. 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 /> w Business Na (DBA) Address ' <br /> z Owner Address. _y <br /> J Firm Partners, Addresses and Telephone Numbers p <br /> a Business Telephone No. Emergency Telephone No. O Z` Z <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title�. "! J Date <br /> Please check Applicable Category (1-7)and_0111.In the Req uired'lnlormation t �. <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 —.—.- Disposal Sites-: <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights& Measures No. <br /> � r <br /> Equipment Parking Address - <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> } <br /> No. of Vehicles Stored' <br /> No. of kchemical Toilets Stored <br /> 3. ❑ 'PERCOLATION TEST <br /> R.S. orIR.C.E.'Name R.S. or R.C.E. No. If <br /> Test Location Test Date/Time <br /> 4.-❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner i Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL IXEACHING FIELD ❑ SEEPAGE•PIT ❑ PACKAGE PLANTS-- <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR";, n © OTHER <br /> .5. 01 CHEMICAL TOILETS �pr July 1, -June 30, 19 i y Y tea, 41f eeoc <br /> Type Construction Disposal Site _ [/ <br /> No. of Un-its # _� Equipment Storage/Cleaning.Location(s)' <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> ;Operator Name '- — -, }' Where Certified ` <br /> Plant Ei -ocation t` 4 ""} r` . '+ F <br /> -- a "`6 <br /> Plant Capacity No. Units Served <br /> 7. ITIALINDRY For July 1, -June 30, 19 <br /> SIZE <br /> Less❑ Than 1,000 Sq. Ft., ❑ More Than1000 Sq. Ft. <br /> ❑ DRY.—'CLEANING—Che' Used/AmouA Mo. <br /> tdome owner or ficeoeed agent's signature cerofisoft following:"1 certify that in the.performancb bt the work for which Ifils permit is issued,l shall not employ any person <br /> in such maom as to become subject to workman's compensation taws of California" <br /> Consrsctors hiring or eub co;ttrecth,g signaUlie,cerx;fies'die following. "I Certity that in'the performance of the iNo`rk for which this permit is issued,f shall <br /> employ persons subject to workman's compensation taws of California" y <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I ordinances, state laws, and rules and reaulations of the San Joaquin Local Health District. <br /> _ -/0 r�� <br /> APPLICANT'S SIGNATURE X , <br /> x FOR DEPARTM T USE ONLY- I�� V <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH © January 1 14ec, <br /> l ed By January 31 T ❑ July 1 &Received By Juay 31 <br /> y BILLING REMITTANC $ REMIT <br /> 1 BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS ' <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER i <br /> OTHER <br /> ' I <br /> Received by T I Date - Receipt No. Permit No. ISSUa0lGe Date Mailed Delivered <br /> r <br /> APPLICANT_RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH'PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />