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Applications Will Be Processed When Submitted Properly Completed. Bsur <br /> ... <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is b mad t Car on siness in the jurisdictional area of the San <br /> �- uin LoealthDtrict- <br /> �i>� Address !/ v <br /> HBusiness Name <br /> z Owner. .. x Address I•. a <br /> AE <br /> J Firm Partne•s, Addresses and 7elepfione Numbers Emergency Telephone No. , <br /> a Business Telephone No.. - - "� ' <br /> -i Contractor Licence No. pate <br /> LApplicants Name (Print) Title: y. <br /> Please check Applicable Category-.(1-7)-and Fill in the Regulr d Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June.30,.19- Disposal Sites <br /> Description(Make/Yr., Color) Y <br /> CAL. License No. CAL, License Renewal No. <br /> Serial No. <br /> Capacity Gal., Weights &Measures No. y <br /> Equipment Parking Address Q <br /> 2. ❑ PUMPER YARD - I <br /> For July 1, June 30, 19 <br /> 'No. of Vehicles Stored, <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST .I R.S.or R.C.E. No. I <br /> R.S. or R.C.E:Name [ <br /> Test cation Test Date/Time Y� ~ <br /> 4.�Ukw SANITATION PERMIT • "~ <br /> 011 <br /> J6b Address/L in �" <br /> A <br /> Owner res � <br /> ❑ �t uJ - ` , <br /> EPTIC AN CESSPOOL EACHING FIELD EEPAGE PITPACKAGE PLA <br /> �I`/y�P ❑ T.EMPOF'I. EW REPAIR (�.i�i7❑ TH <br /> PERMANENT ,vl1 l7"'i <br /> 5: ❑ CHEMICAL TOILETS For'July 1, -June 30, 19 �"' 1� � v <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 Where Certified` <br /> Operator Name <br />,. Plant Location <br /> PI"antlCapacity No. Units Served <br /> r J.; `❑ 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. 9 <br /> k <br /> ,Home ovinerorlicensedagent'aslgnaivraes*tlf7ertl�sfottuwinta="Icerif#yritraltirrthe performanceofthe workfn:which this permit isissued,lshall notcmployany Person <br /> in such manner as to become subject to workman s canpensalian latus of f dliiAftli� <br /> Corltr"tor's hiring°or sub-corstreatiny aig>•le"11- cercf'ss the follawu.3• certify Shat it the perit�lraance of floe work for which this perm[t is issued,I shall <br /> �. ,employ persons subject-to werkmalis compensation laws of California:' <br /> a <br /> I hereby certify that I-have pre red his application and that the work will be done in accordance with San Joaquin County <br /> ' ordinances, state laws;and r a d regul ns of t5a Joaquin oval Health District. <br /> ` APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY . <br /> Fee Is Due: [3 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH January 1 8 Received By January 31 [3 July 1 &Receiveduty 31 <br /> REM IT <br /> BILLING REMITTANCE $ -- AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE - DATE REMITTED AMO NT <br /> w f <br /> FEE i <br /> LESS L_ 4 <br /> PRORATIONPLUS <br /> {[[[[[ <br /> PENALTY <br /> OTHER o - <br /> OTHER <br /> fNo. ssuan a at Mailed. Delivered <br /> Received by Date Receipt No. w <br /> - APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br /> 1601'E.HAZELTON AVE.,P.O.Bo=20D9 STOCKTON,CA�952D1 <br />