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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> r (For Non-Transferable,Revocable, and Suspendable) SEPTAGF. <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> .r LIQUID WASTE <br /> Applica is �nmade n bu 'ness inAhQJiu,icrffrtinral area of the S a Loc I H I Di trict i <br /> HBusin ame (DB Address <br /> aOwn r -14 &AAddress . <br /> Firm Partners, Addresses and h e N j rs.�1 <br /> a Business-Telephone No. <br /> Contractor Licence No. Emergency Telephone No. <br /> . .A ��— <br /> Appti�cantsNarne (Print) `may- :Title bate <br /> Please check Appticable`Cate (1-7)and Fill in the equired fnforrnation. <br /> 1. ❑ PUMPER VEHICLE-PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> ».: -w ti <br /> For July 1, June 3�6, 19 - Disposal Sites <br /> Descriptian�•(Make%Yr�.,`Color) <br /> Serial No. r ��.r CAL. License No. CAL. License Renewai No. "t <br /> Capacity � ,�� Gal., Weights & Measures No. _ '3 <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD j <br /> For July 1, June 30, 19 ! <br /> 1 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST r <br /> R.S. or R,C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. WSANITATION PERMI <br /> Job Addres /Locatio r P <br /> Owper Address <br /> Al, <br /> PTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT . ❑ PACKAGE PLANT [�] <br /> PERMANENT ❑ TEMPORARY NEW❑ REPAIR 1:1 OTHER <br /> 5. 1:1 CAEMICALTOILETS For July 1, -Juhi 30;19 l' "`-�-�- <br /> Type Construction ''!Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) K� <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1 -June 30, 19 +� <br /> Operator Name t ) _#.Where Certified u- <br /> Plant Location <br /> Plant Capacity �f e No. Units Served <br /> - i I <br /> 7. ❑ LAUNDRY For July 1, —June 30, 19' <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,`{ ❑. More Th nA 00Q Sq.,Ft. I <br /> r. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ) <br /> Hoerr awnerorficensedagent'ssignaturecer mesihefofloraing "#CerlffytAat n perforltlasteeMtE4ewD►itforVrh#tfit#}fs ttillti6isststid,Ishallnot tm t <br /> iq si>rh rpanTief as tb'Jeent a str6ject to*_ri kmail s co�itperrsatian laws of f.8lilorr�i; p eY YPersnn s <br /> i Corrtraclnr`s hiringret X <br /> or au6 conctaccir, srer�tnre certii;es the..favdu�ing: "#rertifY that ih ft performance of the work for which this permit is issued,I shall � <br /> emptay.Fursolas sgpject to wurkmali s compensation i�w5 of Califgrriia i; t <br /> b <br /> l hereby certify that.` have prepared,thisi`application and that,the work will be done in accordance with San Joaquin County <br /> i' 3 ordinances state laws, and les and wegu ions- the San Joaquin Local Health District. <br /> APPLIC 4NT'S SIGNATOR'E X <br /> ` '�4FOR DEPARTMENT USE ONLY <br /> } <br /> Fee Is Due =ANNUALLY• PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> r f BILLING REMITTANCE $ REMIT ' <br /> 1 BASE EXPLANATION AMOUNT DUE CHECKED <br /> �r# DATE DATE REMITTED AMOUNT <br /> ,l I � <br /> yFEE <br /> j!/LESS <br /> PRORATION <br /> PLUS <br /> PENALTY- _ <br /> OThER - <br /> , <br /> OTHER ' �_ <br /> _ r <br /> --- -- <br /> Received by '- Date - Receipt No. -Permit No .. Iss once ate Mailed Delivered;"^---__ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,p,0-Box 2009 STOCKTON,CA 95201 - <br />