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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) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> _ W LIQUID WASTE <br /> Applicati is hereby made)o car o i busi ess in a'uns "ctional area of the 5 a ui Local H alt Distric , <br /> Busines �lame (DBA) ' Address <br /> iowners=./l���i> _ ' � Address <br /> Firm Partners, Addresses and Telephone N hers <br /> L Business Telephone No. —116.61. Emergency Telephone No. o� <br /> Contractor Licence No. <br /> Applicants Name (Print) Title \ Date 1,2 <br /> Ptease check Applicable Ca ory (1-7) and Fill in th equtred Information } <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) l <br /> Serial No. CAL. License No. CAL. License Renewal No. J <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&,�Chemical Toilets Stored <br /> 3. W.XP.ERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Lociltion Test Date/Time <br /> 4. 0"SANITATION PERMIT +� <br /> Job AddrepplLocatioLi , 'rJ �✓f '�Li ' t �+I� ' <br /> Owner r �'. . a- ire Address —.�r- <br /> ❑ SEPTIC TANK 11 CESSPOOL ❑ LEACHING FIELD ©SEEPAGE PIT PACKAGE PLANT <br /> ' PERMANENT ❑ TEMPORARY 1-1 NEW REPAIR <br /> ❑ OTHER ( ► <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 W <br /> Type Construction Disposal Site —_ a <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 /> Home ownaror licen3ed aflant's signature certifies the following:"I certify that in the performance of the work for which this permit is Issued,Ishall not employartyperson <br /> in such manner as to hecolne Su hiect to workman's compensttian laws of California" <br /> Contractor's Hring or s+lti-contracting signature certifies 1ha following: 'I certify that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workma is compensailon laws of Calitornia," <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, d rules an eg (ations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X a <br /> FOR DEPARTMENT USE ONLY <br /> Fee is true: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 7 &Received By July 31 - <br /> REMIT <br /> BASE EXPLANATION BELLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT +1, ' <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS — <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ISJ _JSSz <br /> Received by Date Receipt No. Permit No. I uance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEL-TON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />