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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 /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby madeV carry on businesp in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DBA) 1 o Y Address / <br /> z Owner Address — <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. W 4 0 7 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information I- <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 4 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) 1 <br /> Serial No. CAL. License No. CAL. License Renewal No. <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' <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/L9zati//°°n ,a1»G r' <br /> Owner _";1, a .4 ZE' Address <br /> * SEPTIC,TANK 13CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW E] REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 f1 <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 <br /> Operator blame Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 — <br /> SIZE: D Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. h, <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Forme owner or licensed agent's signature wrtifiosthe full ovAng:"I rertifv that l n the performance of thework for which this permit is Issued,l shall not employ any person <br /> In such manner as to berome subject t: wor!araifcein nnsatlor laws c'Ca#ifernl, " <br /> Convractor's hiring or sets-contracting signature c�er°.ifles the fottowing: "I certify that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workmans compensation laws of California:' <br /> 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 ru! and regul tions of the San J in Local Healt trict. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE j DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE A s 11 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER Q <br /> OTHER <br /> Received by Date Receipt No. Permit No. - - Iss ante Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />