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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> s. APPLICATION <br /> 1 (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 /> ,Business Name (DBA) __- _ Address/ <br /> a Owner r`l0 ��"� --_ Address �D93 �T -���✓ '� M,,� 9-S2GS <br /> u Firm Partners. Addresses and Telephone Numbers <br /> CL Business Telephone No.4/2 b!!Z) AM_--57 - Emergency Telephone No. <br /> Contractor Licence No. _ ����� <br /> a Applicants Name (Print) 1DOo 4: -2- sc.A Title �1�� 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. 0 PERCOLATION TEST <br /> R.S. or R.C.E. Name W4/ e C�7 aS.or R.C.E. No. <br /> Test Location 9AA41e,4, Test Date/Time <br /> 4. ❑ SANITATION PERMIT Jq <br /> Job Address/Location - - <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 orAcansed agent's signatureaertHlesthe following:"I certify that in the performance of the work for which this permit is issued.I shat)not employ any person <br /> in such manner as to become subject to workmans compensation laws o!Cal0orf4a.' <br /> Contractor's birinip or sub-contracting signature certiKtas the fohov.ing: I certify that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's compensation laws of Calitolnia. <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, a rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X - -FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> Z AMOUNT <br /> FEE O- -! l7 - <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receiv 'b, Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> PPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />