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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTneAppncauon. <br /> APPLICATION <br /> _- (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH "PERMIT <br /> LIQUID WASTE <br /> Applicatio is h reby made to rry on bu 'Hess in the jurisdictional area of the San Joa uin Loca alt istrict ffS � <br /> Business Name (DBA) -1 Address. z <br /> z E Adds g I <br /> a Owner <br /> __A <br /> Firm Partners, Addresses and Telephone Numbers r <br /> aBusiness Telephone No. 4 Emergency Telephone No; I <br /> � <br /> Contractor Licence No. " <br /> �ARPlicants Name (Print) a Title /Q��64~ Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information;, J ) <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) r <br /> CAL. License No. CAL. License Renewal No. <br /> Serial No. i+ <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 Stor <br /> 3. X PERCOLATION TE `�` f �d. 'A.S. or R.C.E.No. <br /> R.S.or R.C.E. Name D <br /> Test Location Test Date/TimeAtc <br /> `, S <br /> q. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER \„ <br /> 5. ❑ CHEMICAL TOILETS For July 1,.-June 30, 19 <br /> Type Construction Disposal Site r <br /> No. of Units Equipment Storage/Cleaning Location(s) � <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified . <br /> Operator Name <br /> Plant Location - <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 I <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home ownor of licensed agent's signature certifieathard(!n%4na:"I cer1ifythaf in.ha Gerfcrrnanceof thew ork for which this permit Is issued,f shall not employ any person <br /> in such manner as to beco 1A su�tect to warfcmac ccmpnnsetir !a us ct(aliinr <br /> I i t ; ,t ,rr;�;i +t;at•":- 1r nr;E.7tma:1 ,:a:t"1 r!work-;orlul;ictl this permit is issued.I Shalt 1 <br /> Contractor's•hWirio or s•ab r ntrncting niq 1e-.r. Y' 1 <br /> employ perso i$suuj8et til W:,r k r, <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 les d regul _:ons of the San aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> _ FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH C3 January 1 &Received By January 31 ❑ July 1 &ReceivedBy Jbiy 31 <br /> REMIT <br /> € BILLING * _ REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION , <br /> ' PLUS 1 r, <br /> PENALTY <br /> OTHER <br /> OTHER <br /> If 3- 8402 <br /> Recesved Dat - - Receipt No: f " Permit No. 1 suan Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELT AVE.,P.O.Box 2009 STOCKTON;GA 95201 <br />