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Applications Will Be Processed When Submitted Properly Completed. 13esure ro coign 1 ormpt-1 a••� <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applic n is hereby ade tocar on s6 e;S i the jurisdictional area of kh an J quin Locai He h District <br /> rn Busine ame (DBA Address <br /> I- Address <br /> a Owne <br /> J Firm Partners, Addresses and elephone mgrs <br /> aBusiness Telephone No. Emergency Telephone No., ., <br /> Contractor Licence No. <br /> Title Date <br /> Applicants Name(Print) ` <br /> Please check Applicable,Cat ory(1-7)and Fill In a Required Information <br /> ,.1. ❑ PUMPER,VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1,z June 30, 19 Disposal Sites <br /> f <br /> Description(Make/Yr.,-Color) <br /> CAL. License No. CAL. License Renewal No. <br /> Serial No. t <br /> Capacit — 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._ - R <br /> Test LL ation Test Date/Time 1 <br /> 4. 1=1 SANITATION PERMIT <br /> . + <br /> Job Add /Lo ation —L AJ � <br /> Owner Address Z <br /> I�W, �SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT OT EAR <br /> GE PLANT <br /> LPPERMANENT ❑ TEMPORARY GeNEW <br /> 13 REPAIR <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 /> Where Certified <br /> Operator Name t <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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}t 4 & gW& g �ssd/na°uctihetureertt' esthehNlowing:"IMrtifythatintheperfDrmameoftheworkforwhichthis permit is Issued,I$hallnot em lu any <br /> pg­ <br /> in ,... <br /> such manner as to become subject to workman's compensation laws of California ' <br /> Con"",for's hiring or sub-contracting signature cwtifies the twlowing: 1 certify that io the performance of the work for which this permit is Issued,I shaU, p <br /> employ persons subject to workman s compensation laws of California." <br /> } <br /> f <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County s <br /> F ordinances, state laws, an ules and r gul ns f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT-USE,Q.NLY.r.,,..,•. <br /> I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedByJ-IY'31 <br /> MIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS i <br /> PENALTY <br /> OTHER f Y <br /> { <br /> 1 <br /> OTHER r <br /> Received by <br /> Date Receipt No. Permit No. Issua a Date Mailed Dekivered <br /> 1601 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,GA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES li� f- P <br />