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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 �lJ <br /> ENVIRONMENTAL HEALTH PERMIT ) 3U <br /> LIQUID WASTE / <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District -J- <br /> r Business me DBA) Address <br /> a Owner, y Address��0 61 <br /> J Firm Partners, Addresses and Telephone Numbers 33 �O C� <br /> IL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title 7 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 gKemical Toilets Stored <br /> 3. PERCOLATIO TEST <br /> R.S. or R.C.E. Namur �'✓Y C - R.S.or R.C.E. NIl Y i�cv� <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION 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 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 /> ❑ DqY CLEANING Chemicals Used/Amount/Mo. <br /> Nome owner or ticenssd agent's signmuro rArt'rfle-tho 4ollowing:'1 certify tb'it in tho performance of thework for which this permit is issued,I shalt not employ any person <br /> in such manner as to become subject to vrorkmali s compensation ta'g's of fafift:;air ' <br /> Contractor's hiring or sub-contracting signature certeies the following: 1certify that in the performancE ci the work for which this permit is issued,I shall <br /> employ persons subject to workman's compensatiun laws of California:' <br /> I hereby certify that I have preparod this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and)uiejlAdd regulations=uin Local Health District. <br /> XPPLICANT'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 AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 15 Q LX> <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 />