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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Nan-Transferable, Revocable;"and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> mApplication is>c*byrnade to cyl on bu ess" the jurisdictional area of the Sam q�I�n�L-oc ealth Di t�rict � <br /> Business Name D A d d rW s;�7fJ <br /> z Owner Address <br /> a _ <br /> Firm Partners, Addresses and Tele hone um ers <br /> aBusiness Telephone No. Emergency Telephone No. x <br /> Gontractor Licence No. _ <br /> L Applicants Name (Print) Title10_ -n-F1'� Date <br /> Please check Applicable Category (1-7)'and Fill in the.Required Information ;;yf ,; ;, <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, - June 30,19 x - Disposal Sites - <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. .,CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD t <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored i <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 1►J �f ` �^ <br /> Job Address/Location E �L! <br /> Owner `Address <br /> ❑ SEPTIC TANK CESSPOOL 1>2fEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. © CHEMICAL TOILETS For July 1, -June 30, 19 a" X�/� <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 Name - •Where=Certified--, <br /> Plant Location <br /> Plant Capacity 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" <br /> ❑-DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Hoare ownaror licensed 3grrt's-A7qnnYq rG C6 t tiQE1hg4r}}}0WkRr,; tf at in the performance.of the work fnr vAic4 chis perm itis issued,I shall riat employ any person <br /> {"sn such manner as to become su ject to titi r.r12r"; Ccr:wi a.i�;. 4 <br /> -Contractor's hiring or sub-cortracuiig 5:gnature certifiea 1h2 :allowing: I certify'that in the performance of the work for which this permit is issued,l shall <br /> employ persons subject to workman's cv'lpensatip:i:a°r's of California." ( f <br /> I hereby certify that I have,pre ared this application and that the work Will be done in accordance with San Joaquin-County <br /> ordinances, state laws, and,r 'es nd r lations the San Joaqu Local Health trict. <br /> -APPLICANT'S SIGNATURE X , <br /> ,cr_/ <br /> OR DEPARTMENT-USE ONLY < <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ -�' REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED lam" AMOUNT <br /> FEELESS <br /> PRORATION i + .� . •. K <br /> PLUS a A r 3 <br /> PENALTY Q �✓� <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No. Issuance 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 />