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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 r ade t rry o usi ss in the jurisdictional area of the San Joaquin Loc ealth District n <br /> cusiness Na DBA} <br /> Address r�.� <br /> aOwner Address <br /> J Firm Partners, Addresses and T Ihone Numbers <br /> o- Business Telephone No. (j L Emergency Telephone No. <br /> Contractor Licence No. <br /> I Applicants Name(Print) DateTitle <br /> Please check Applicable Category (1-7)and Fill in the Required Information 1 <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. 0 n <br /> Capacity Gal.,Weights&Measures No. r` <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. ❑ PERCOLATION TEST <br /> R.S.or R.C.E.Name R.S.or R.C.E.No. <br /> Test Location __ Test Date/Time <br /> 4, 2<SANITATION PERMIT n <br /> Job Address/Location <br /> Ownerr - Address <br /> C3 SEPTIC TANK ❑ CESSPOp ,��EACHING FIELD EEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ZXREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> 'pe Construction Disposal Site , <br /> .io.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 /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> Home ounterorlicensed agent's signature cert fiarthe follow1ng:"!Cortify t`?`.I ntheper'ormance of the work for which this pertl:it isissued,I shall not employ any Person <br /> in sJc',,manlier as to become subject to war%mari's:GT.�,e052'ip::%�L•:i .'::,i0:;Y <br /> Contractor'E hiring or "b-eontr3ctirg- work fer Which MIS permit IS'sued.i shall <br /> employ persons subject to wcrkraan'scampensa;ioi;la•kiti bl Gafih:rl; . <br /> I hereby certify that I have prepared this appli ation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,and r and ula ns f the San Joaq LOCaI ea District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT U OAit.Y f <br /> UI/ <br /> Fee is Due: 12 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH El January 1 8 Received By January 31 ❑ July 1 fl Receive ly31 r <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION — <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. ISSLafXe UaI616 Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.fox 2009 STOCKTON,CA 95201 <br />