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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> �;. (For Non-Translerable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl icatio is her by de t carry usi s 'n the jurisdictional area of the S�aq cal Health rict <br /> Busines a DBA) —Address ��r ---- <br /> a Owner ___ <br /> _- " . AddressP� <br /> - - <br /> U Firm Partners, Addresses and Tele one Numbers—. - "-• -- - <br /> aBusiness Telephone No.— CP3- Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) Title Date <br /> Please check Applicable Category(1-7)and Fill In the Required Information i <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30;A9 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 t <br /> For July 1, June 30,-19. <br /> No:ofyegc-les Stored,,- <br /> No.of Chemical Toilets Stored' ---- - - <br /> 3. 11 PERCOLATION TES7_,:� <br /> R.S.or R.C.E. NO"4 <br /> R.S.or R.C.E. Name — <br /> Test Location _ ___.._. Test Date/Time t - <br /> 4. SANITATION PERMIT j <br /> Job Address/L cation _ _20Owner __ Address <br /> El SEPTIC TANK ❑ C SSPOOL M—CACHING FIELD G--SEEPAGE PIT ❑ PACKAGE PLANT OVIV, <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 94'REPA e C3OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site 3J- ---� <br /> No.of Units Equipment Storage/Cleaning Location(s) A d <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified — - <br /> Plant Location - <br /> No.Units Served <br /> Plant Capacity y? <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 t r LJ f <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000.Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. -- - <br /> Homeowner rwftenfed agent's signelaire,cortifies tlterfoAowh+g:1 coir lly thal`in the portorm ance of the worts for which this permit is Issued.I shall not employ any person <br /> in such manner as to become subject to workman's rcrrponsation llc•s;,4 Califortil r' c },� 7 <br /> Contractor's hiring m sub-contracting signature certifies the toitowing:' i certify=tt�at io the performance of the work for wtiich this permit is issued.t shall C <br /> employ persons subject to workman's compensatfon laws of Caliternia <br /> t <br /> I hereby certify that I have prepared this applicatio nd that/he work.will be done in accordance with San Joaquin County <br /> ordinances, state laws, an Ind re lations an aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> L . <br /> c <br /> FOR DEPARTMENT.USE ONLY_ , <br /> Fee Is Due: ❑ ANNUALLY Cl PER UNIT ❑ PER SITE 1:1 EACH ❑ January 1&Received t)y January 31 ❑ July 1 d Received By July 31 <br /> _ REMIT <br /> I EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE <br /> f DATE DATE REMIT <br /> FEE . <br /> LESS <br /> PRORATION - �.. <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER _ <br /> Received by Date - Receipt No. Permit No. uanc6 Dare Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O. i 2009 STOCKT N,CA 95201 <br />