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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> 'tP6r Non-Transferable, Revocable,and Suspendabho-.0 SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application Is/he�r S to c on ss in the jurisdictional area of the San Joaquin Local Health District J d) <br /> Business Name (D .Yin itCIu,y /f Address 1,7Q's— <br /> aOwner .� ,� �2r[ Address >> <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Z Emergency Telephone No. Q <br /> 11 Contractor Licence No. <br /> Applicants Name (Print) Title �8� Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <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 /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <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. 13SANITATION PERMIT (V <br /> Job Address/Location <br /> Owner Address II <br /> (=SEPTIC TANK ❑ CESSPOOL LEACHING FIE SEEPAGE PITT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARYNEW REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site C <br /> No. of Units Equipment Storage/Cleaning Location(s) n <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 h <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. R1 <br /> Home ehsfcanwlnn I ehh ,._•. �`".epsrfarmanca of the work for which this permit is issued.Ishall not employ any person— <br /> in such manner as to become subject in vo ltI s s r:,''finerrsatlon law n, <br /> Contractor's hiring or sub-com:ictrnq e;g.lsalry ::orl;?ies .h;. fahowmu: 1 certify that in the performance of the work for which this permit is issued I shall <br /> employ persons suJ ect to workman's cwnpensatioo lax.ul Caail f ia.' <br /> I hereby certify that I have prepared this ap lication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and/rJ/+�s and regula ons of San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X !y <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 aKJulyBILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNTDUE <br /> FEE Ill Q <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit Na Iss ante vate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.9oa 2009 STOCKTON,CA NMI <br />