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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 /> A. ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application � hereby rWde to carry on bu in in th ' riWictional area of the SJ aquin Lp g h istrict <br /> Business Name {DBA Address _ �l�4( <br /> z Owner Address _....: _.. <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. • Emergency Telephone No. <br /> Contractor Licence No. - . ; <br /> Applicants Name (Print) .;..Title R,Date <br /> Please check Applicable Category (1-7)and Fill.in the Required Information rr s } <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) - + <br /> i <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Calor) (� <br /> Serial No,- CAL. License No. CAL. License Renewal No. .moi <br /> Capacity -Gal.,Weights R Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD - <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored 1 <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. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Qwner - Address <br /> SEPTIC TANK ❑ CESSPOOL �q LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT' <br /> PERMANENT ❑ TEMPORARYNEW 1:1REPAIR OTHER a7G107X12 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -Juane 30, 19 r <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 r <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 /> HomeoHmerorCcensedagent's alonaturecartifi"thalclltswing:"icer±ify±hat i;theperfosmailce of thasvcrk ferwhich this permit is,issucc,l shall.not employ any person <br /> in such manner as to hecome subject to+r erkmaris cenpv lsatlon rates a C�,if a 2, s ,+4; ..d v,Lr <br /> Contractor's hiring or sub-corttracting nignat;mf rw- i t„e ,oto n,y �I certify that intra. e:turmarce 0721ne y ork far which this permit is issued,I shall <br /> emPlay persons subject to workman's cr7mpa,isztion <br /> skiff <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with-5an?Joaquin County <br /> ordinances, state laws and r and reg ions of the San Joaquin Local Health DistricO-4 <br /> APPLICANT'S SIGNATURE X <br /> LL FOR DEPARTMENT USC.ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH,t ❑ January 1 &Received 5'Jar"tuary,31 �,} ❑”July s1,8 q_4ce v�d By July 31 <br /> —REMIT <br /> BILLING _ REMITTANCE "S <br /> BASE c EXPLANATION AMOUNT DUE CHECKED -• <br /> DATE DATE REMITTED �- AMOUNT <br /> FEE <br /> LESS <br /> PROBATION <br /> PLUS <br /> PENALTY _ <br /> OTHER !- <br /> OTHER <br /> o L{ $ v <br /> Received by Date Receipt No. Permit No. Assuande Date Mailed Delivered <br /> APPLICANT RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br /> - r <br />