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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 /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA) Address <br /> ? Owner t Address /o .s . A a� <br /> a <br /> 2 Firm Pa ers, Addresses and Telephone Numbers <br /> Q. Business Telephone No. 90.�C 'd�I3 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) /y Title 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. X PERCOLATION TE �'�'//' /�6 J <br /> R.S. or R.C.E. Name K/ATL R.S. or R.C.E. No. <br /> Test Location G U 6 4 Test Date/Time _ <br /> 4. ❑ SANITATION PERMIT 3---FEST S �— <br /> rJ <br /> Job Address/Location <br /> 1 <br /> Owner Address CJ <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT 0 <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> ti <br /> No. of Units Equipment Storage/Cleaning Location(s) m <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 or licensed agent's signature certiflesthefollowing:"I certify that in the performance of the work f orwhich this permit is issued,I shall not employ any p,,, <br /> in such manner as to become subject to workman's compensation laws of California:' <br /> Contractor's hiring or sub-aontraetimq signature certifies ::te following: 1 Certity 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 California.- <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, and rules and regulations of the San Joaquin 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 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED A$ 0 NT DUE CHECKED <br /> Ano MOUNT <br /> FEE <br /> FEE r�� ,f -13-x1 b`134-o <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Recei d by 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.Boz 2009 STOCKTON,CA 95201 <br />