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F =� <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application."• <br /> i APPLICATION r <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH,PERMIT <br /> LIQUID WASTE <br /> Application is hereb�(made to carry on business in the jurisdictional area of the San_ Joaquin Local Health District <br /> rn Business Name (DSA) -Address <br /> F_ <br /> Owner. •�. v .l _ ca`yF bR�r Address _3� g _ s,. i'.G`�,. .�4 n <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a aBusiness Telephone No., _ Emergency Telephone <br /> l - -- — <br /> Contractor Licence No. !r <br /> LApplicants.Name (Print) _ 'r- 1C` .. .-;Title Date o + <br /> Please check Applicable•Category(1-7)and fill in the Required Information <br /> 1:= ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> i <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No. CAL. License Renewal No. <br /> x <br /> Capacity' Gal.,Weights & Measures No. <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 r <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location9� �.. % g h Q.V1d <br /> Owner `r— Address I' <br /> 91SEPTiC TA4 ❑ CESSPOOL K'LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY - ❑ NEW ❑ REPAIR ❑ OTHER ! <br /> 5. 11CHEMICAL TOILETS For July 1, June 30, 19 <br /> Ui <br /> Type Construction v — Disposal Site <br /> No. of Units Equipment Storage/Gleaning Location(s) <br /> 'L 6. ❑ PACKAGE TREATMENT PLANT For July.1„June-30, 1.9 '! <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity - No. Units Served r <br /> *1;7. ❑ LAUNDRY For July 1, -June r30, 19 t <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> I�❑ <br /> RR Y CLEANING, Chemicals Used/Amount/Mo. <br /> > �maownerorlicensedagent•sSignatureterifiesibefollowing."I certify thal in the P�darmancc of the wark f orwhich this permit is issued,I shalt not employany pers'-'.rl (� <br /> in such manner as t0 become subject to workman's Compensation laws of Caiiforni�," <br /> Contractor's hiring or Sufi-contracting signature certifies :f1�l�foltouving: 'I Certify that in the performance of the work for which t,`tis permit is issued,I shad <br /> employ persons subject to workman's cornpensation laws of Caiiiornia", <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the,San Joaquin Local Health District. <br /> � i <br /> APPLICANT'S SIGNATURE X <br /> -- -� <br /> FOR DEPARTMENT USE ONLY <br /> 3 - <br /> �, ` Fee'Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE - EXPLANATION AMOUNT DUE ' CHECKED <br /> t- DATE OA7E REMITTED AMOUNT <br /> FEE �1 L J + 4k5 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> dh I <br /> Received by ate I Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 <br /> i� <br />