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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApphcanon� <br /> APPLICATION � /`� <br /> (For Non-Transferable, Revocable;and Suspendable) SEPTAGEIY <br /> ENVIRONMENTAL HEALTH PERMIT / <br /> LIQUID WASTE ' <br /> Application is hereby made to carry on business in the jurisdictional area of San Joaquin Local Health Dis rlct <br /> NBusiness Name (DBA) <br /> "Address=�` <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a phone No.Business Telephone No. ' Emergency Tele <br /> a 3 ,;. <br /> Contractor Licence No. <br /> LApplicants Name (Pring it- T1:J -. y; Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Disposal - - <br /> For July 1., -' June 30. osal Sites 19 -- - -�.... P <br /> Description(Make/Yr.,Color) -._ <br /> L4�ense'.iJo � CAL. License Renewal No. <br /> Serial No. ) �� <br /> Capacity Gal'.,Weights,& Measures No. {' <br /> Equipment,Parking'Adc.ress <br /> 2. ❑ PUMPER YARD 'i t <br /> For July 1, June 30, 19f w <br /> No. of Vehicl s Stored r, # x <br /> No. of Chemical Toilets Stored ! #P (i a <br /> 3. ❑ PERCOLATION TEST ' r { J T <br /> R.S. or,R.C.E. Name. R.S.or R.C.E. No. TAY <br /> Test Location <br /> Test Date/Time ; , <br /> 4: ❑ SANITATION PERMIT <br /> Job Addre s/Location <br />( Owner� "w TE!t—& f 5 Address 4 <br /> ❑ SEPTIC TANK. ❑ CESSPOOL S EACHING FIELD SEEPAGE PIT PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW J ' r�REPAIR ❑ OTHER <br /> I 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type.Construction Disposal Site <br /> No. of Units t Equipment Storage/Cleat iAng Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19'r�� . r <br /> ! '1�1 Where Certified - <br /> Operator Name -. <br /> i Plant Location t <br /> No. Units Served } <br /> Plant Capacity r <br /> i 7. 13LAUNDRY For July 1, -'June 30, 19 _ !. or + <br /> -SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq Ft. <br /> ❑ DRY CLEANING, Gherridals Used/Amount/Mo f <br /> i <br /> Rrr±'SSi rtAtlS7'flCer'I:snegSt�!vlSgt,in�:"1 r_. C,:y �ro•^'�"• _...Y,.-I'this-pP.ri:Iti3155L1ed,l shall.not employanyperson <br /> Home owner or licensed ag S <br /> In Such manner as to became subiect to vrorktr, o : :.3:-' •:'v^ai r.a= ycl k ipr''hicll thss oermil is issued.I shall <br /> Contractor's hiring or sub-contractin int. torr _'s'" ry ,',ova., �.. ;_ ,.. �" � � _ <br /> employ persons subject to workman s cumpetssati:ja la;';s ut Cai;.umia:` <br /> t <br /> I hereby certify that 1, h p pared this application and that the work w' be one In with San Joaquin County <br /> t <br /> ordinances, state law nd r e and regulati of the S J aqui ealth istrict.T r. <br /> APPLICANT'S SIGNATURE4. <br /> . <br /> i FOR DEPARTMENT USE ONLY t - <br /> PER <br /> I <br /> I <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By JAuary 31. ©July 1 &Received By July 31 <br /> REMIT <br /> 'BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE .REMITTED }" AMOUNT <br /> FEE ��� <br /> ol <br /> LESS <br /> PRORATION <br /> PLUS <br /> J / 1 <br /> PENALTY,e,_,d,-.^. 41- <br /> OTHERv ..: rsk <br /> OTHER t r <br /> - Received by Date ' `Receipt No. Permit No. r1 Issuance 1e A Mailed Delivered L <br /> L4PPLICANT=RETURN ALL COPIES'f0: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEL-TON AVE.,P.O:Box 2009 STOCKTON,CA 95201 r <br />