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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> x.41 (For Non-Transferable, ReV06161'e;`a6d Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WAST " <br /> Application 's hereby mad to carry on business in the Jurisdictional area of the_SS7an Joaquin Loca Health District.,, h <br /> Business Name (DBA) �' - Address,,- �i <br /> z Owner Address . <br /> a <br /> Firm Partners, Addresses and Telephone Numbers - <br /> J p <br /> ale hone No. <br /> CL Business Telephone No. 6 ifs� � - "•' Emerge.ncy Te p _ <br /> Contractor Licence No. - I '3 <br /> ti Date... p� <br /> �Applicants Name (Print) •Title <br /> Please check Applicable Category (1-7) and_Flll�in the Required-If or ation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,-=-:-�:.June 30, 19 Disposal Sites- _ - <br /> Description(Make/Yr., Color) ��" t <br /> KCAL. License Renewal No. <br /> Serial No. '.� CAL. License No. <br /> Capacity Gal.,Weights R Measures No. 1 <br /> ° . <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD I k+ <br /> For July 1, June 30,.19 ". --..,..." "... ...- <br /> No. of Vehicles Stored <br />! No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST N <br /> R.S. or R.C.E. Name —R.S. or R.C.E. No. E <br /> Test Location ILIII` Test Date/Time <br /> 4. 0 SANITATION PERMIT 1!I •• �' <br /> : <br /> Jab Address/Local �on <br /> I Owner 11 Address �`t' a r <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT.' ❑-PACKAGE PLANT T <br /> ❑ PERMANENT 11 TEMPORARY ❑ryNEW ;. 1 REPAIR N.' ❑ OTHER i <br /> 0 <br /> t 5. C3 CHEMICAL TOILETS For July 1, -June 30, 19 ° + <br /> Disposal Site <br /> r " Type Construction - <br /> } No. of Units + II�, Equipment Storage/Cleaning Location(s) <br /> 6. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name PP - Where Certified ° <br /> Plant Location �� x <br /> Plant Capacity NN a 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. t <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo, <br /> Home mnmer orlicansed agen s's signstura cartif°es the fell1owinp:"I Mrtify that in the prrformanceof the work forwhich this permit is issued,i ahallnot employ any pe rson <br /> 1p such manner as to became subject to tvorkm An r cempensaf ian i,4ws of California <br /> Contractor's hiring or sut°-cootmctiflg �4rau°rc ewlitif-,ftte wir wing: '1 certify that in the performance of the work far which this permit is issucsf,I shall <br /> employ persons subject to workman's compensation laves of Caiilrt slid. F , <br /> i t <br /> i I hereby certify that :have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws�,, ancl r d ovula ' ns of the S uin Local Dis rict.: <br /> APPLICANT'S SIGNATURE X . <br /> L ( FOR DEPARTMENT USE ONLY <br /> s <br /> Feels Due: ❑ ANNUALLY ❑ PER UNIT- ❑ PER SITE Cl EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ C REMIT <br /> ¢ BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE '.�.+.��DATE REMITTED , AMOUNT <br /> • FEE <br /> LESS <br /> l PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER .,•:� .. u. . .,..e }.� .. --- <br /> Received-by Date Receipt No. s Permit No. Is// ante ate ailed Delivered _ <br /> APPLICANT—RETURN ALL COPIES Td: ENVIRONMENTAL HEALTH PERMIT/SERVICES "1601 E.HAZELTON AV ., .Box 2009 STOCKTON,C,A 95261 - <br /> II�' Ga <br />