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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) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> ppllcatlon Is hereby made to carry on b iness in the jurisdictional area of the San Joa n Local Health District <br /> r Business Name (DBA) �M41- s/ �� D �� J73 Address �LSz�1 X66/ �aE�GIC S7—� < i <br /> a Ownerr�!)C1AI Address 3i <br /> J Firm Partners, Addresses and Telephone Numbers 209 96U 61.22 47 <br /> aBusiness Telephone No. Emergency Telephone No <br /> Contractor Licence No. oe <br /> L Applicants Name (Print) ) �� Title AAffdP ! 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. heroical Toilets Stored - <br /> 3. PERCOLATION TEST <br /> R.S.or R.C.E. N R.S. or R.0 E.No. <br /> Test Location; Test Date/Time <br /> 4. ❑ SANITATIO PERMIT <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 r 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 owneror>koneed the workforwhichthis permit isissued,ishallnot employ any person <br /> in such manner as to become wbject!a workman:;i;ompeu+ aticn Ibtws of C torr:., <br /> Contractors hiving or sub-conrraeiing signature cerifts th isoNowing;, 'I certity that In the perfo anoe of the wo which this permit is issued,l shall <br /> employ persons subject to workman'&compensation laws of California" <br /> I hereby certify that I have pared this applicaticp and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,/a eS an r tions a Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee 15 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 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE Q ZDV -- <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />