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.. - t <br /> - <br /> Applications Will Be Processed When Submitted Properly Completecl <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> r Application is here y made to carry on business in the jurisdictional area of the San Joa yin Local Health District <br /> Address <br /> H Business Name{DBA} Address <br /> i <br /> zOwner <br /> a - J <br /> j 1 Firm Partners, Addresses and Telephone Numbers _ Emergency Telephone No. <br /> CLBusiness.Telephone No. ' <br /> Contractor Licence No. TitleY ..Date_ <br /> LApplicants Name (Print) G <br /> i 7 and Fill in the Required information <br /> Please check Applicable Category (_- ) C� <br /> 1 ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No, <br /> Serial No. CAL. License No. <br /> ' Capacity <br /> Gal.,Weights &Measures No. <br /> Equipment Parking Address - <br /> 2. ❑ PUMPER YARD - <br /> For July 1, <br /> June 30, 19 <br /> � <br /> I No. of Vehicles Stored ) ; <br /> No. of Chemical Toilets Stored 4 <br /> 3, .❑ PERCOLATION TEST r1 <br /> r = R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT <br /> + Job Address/Location Address <br /> Owner a t ❑ PACKAGE PLANT <br /> + <br /> 11 SEPTIC TANK E] CESSPOOL SIF LEACHING FIELD ❑ SEEPAGE PI ❑•OTHER' <br /> 11 PERMANENT <br /> ❑ TEMPORAFIY ❑ NEW REPAIR .� <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 , ,,,e,I �jFGrxG'►/� <br /> Disposal Site <br /> Type Construction <br /> Equipment Storage/Cleaning Location(s) <br /> No. of Units <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 f t � Where Certified <br /> Operator Name i f <br /> Plant Location <br /> r No. Units Served <br /> Plant Capacity . <br /> 7. ❑ LAUNDRY tFor JuIj,1,.-June 30, 19 <br /> SIZE: El Less Than 1,000-Sq"Ft ' More Than 1,000 Sq.'Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> }tvmeowneror.licanaedagent'ssigttaturecartifis8thefofloty.nq. Icertifythstintiseperformanta.ofthe tivor4 forwhittsthispermitisissued.lsh fin4tamPlayanypersan <br /> in such manner as to becoma sub;. t in Ymrkmatl's C4i;l,�Cl?yaiiQil ic�1�':i O+i..'1.irrl+l7t r <br /> Contramor's hiring or sub-cantracting Signature cenffiec the frAlowillg: I celfity That in the performance of the work for which this permit is issued,I shall <br /> employ persons sulriect to workman's tompensatlon laAs of Caiitornia" <br /> I hereby certify that I have prepared this-application-ands at he work <br /> LocalHealthDistricts done in accordance with San Joaquin County <br /> ordinances, state laws, and rules an regulations of the Sa Joaquin ✓�� �� <br /> :APPLICANT'S SIGNATURE X ` T <br /> „K t <br /> -FOR DEPARTMENT USE ONLY <br /> d <br /> Fee Is Due' 11 ANNUALLY ❑ PER UNIT ❑ PER SITE Cl EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By 31 <br /> IT <br /> - f BILLING REMITTANCE $ J 'AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED - AMOUNT <br /> FEE 141 <br /> _r <br /> LE55 •� <br /> PRORATION - <br /> -PLUS <br /> PENALTY <br /> OTHER <br /> OTHER # <br /> Mailed Delivered <br /> Receipt No. i Permit No <br /> Issua ce Date <br /> ReCe[ved by Date 1601 E.HAZELTON AVE.,P.O.evx 20179 STOCKTON,CA 95201 <br /> - APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />