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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ,it Non-Transferable, Revocable, and Suspenciali SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio is hereb yjhadp to carrru s in the jurisdictional area of the San Joe jil Local FJeall DJ'.Stric T <br /> »Business a (qaA) ��// LtAddress �yf/ S� GCC <br /> iOwner le Address .1 17 1/�we r r r <br /> Firm Partners, Addresses and Telephone Numbers 7C/r'—2 R11 f� <br /> °u Business Telephone No. �3«�; Emergency Telephone No. c] �'� <br /> Contractor Licence No. c �— <br /> L Applicants Name (Print) - /� � Title <br /> Date "36 V-J <br /> Please check Applicable Category(1-7) and Fill in the Required Information I <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) W, <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. C�VXNITATION PER IT o _� <br /> Job Address/ ation .� L4L- <br /> Or•��w�ner Atse&aI Address t' <br /> ,�^utPTIC TANK ❑ CESSPOOL Cil-'CEACHING FIELD B'S1=EPAGE PIT ❑ PACKAGE PLANT <br /> u PERMANENT ❑ TEMPORARY 111-NEW ❑ REPAIR 13 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 N <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 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 owner orlieen®d egem's9ign6tureeertifteethe following:"I certify shat In the performance of the work forwhleh this permit Is Issued,I shell not employ any 001110" <br /> In such manner as to become subject to workman's compensation!aws of CA!arnia." <br /> Contractor's hiring or nub.conlractin ::1,�,v,.• ser.!::., ,•. =A'ovanr, "I cort6y that In the performance of the work for which this psrmlt Is 1e11110d,I shall <br /> employ persons subject;c w, 3;o �rwat:3n lays a i <br /> I hereby certify that I have prepared this application Ad that Te work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an nd re lations oft J urn Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Recelved By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATIONBILLING <br /> DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT ,,L" <br /> FEE C3 <br /> LESS h <br /> PRORATION R <br /> PLUS `7\, <br /> PENALTY <br /> OTHER <br /> OTHER <br /> v <br /> Received by Date Receipt No. Permit No. uen Dete Me led Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.P.aoa 2009S�TfQCKTON,CA 95 1 <br /> W �✓ I! p� <br />