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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 isreby made to arryan busin sin the j risdi tional area of the Sa/n�Joaquin Local Health District.. h <br /> y Business Name (DBA f �Addre''S's � "� <br /> L <br /> z Owner Address , <br /> a <br /> Firm Partners, Addresses and Telephone Numbers - <br /> aBusiness Telephone No. d Emergency Telephone No n j <br /> Contractor Licence No., - +. <br /> Applicants Name:(Print) Title (late <br /> Please check Applicable Category(1-7) and Flll in the Required Information , r;: ti il,�: 4i, ' �, i f'n <br /> 1: ❑ PUMPER VEHICLE PERMIT,REGISTRATION (FOR EACH VEHICLE) - <br /> —For1; -`Jurie 30,19~ j — Disposal Sites ... -.. _. .._ <br /> Description(Make/Yr.,Cotor.). <br /> `- <br /> `serial.No. CAL. License No. CAL. License Renewal No. <br /> Capac y `"�` -Gal.,Weights & Measures No. <br /> a <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD ! <br /> For JUIY'11 <br /> "June 30 i9 f '1 <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 L ation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Addr Locati n <br /> O,wn Address <br /> L EF <br /> 1C TANK "❑ -CESSPOOL LEACHING FIELD SEEPAGE PIT C1 PACKAGE PLANT <br /> ❑"PERMANENT ❑ TEMPORARY 11NEW 0 REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 f1 # -- <br /> Type Construction Disposal:Site I ' <br /> • No. of Units Equipment Storage/Cleaning Location(s) ; <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30 19 <br /> i Operator Name - - - ` Where Certified <br /> Plant Location ` }` , .Y <br /> i Plant Capacity ,".No. Units Served <br /> � r <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19— <br /> SIZE: <br /> 9 SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft., s <br />( ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Homeowner<orlie errazdagam's s3g+eeture certitins thefotlawing:'9.Certif�0hat In theperiormance otfh-ework for vlhieb this permit is issued,I shalt not employ any persOP <br /> j in such manner as to become subject to workman's comper:matiort taws,of Ca(ifortl a <br /> Contractor's h;nnq or sub-contracligg s3gnatuwe ceitirie'_' thn'€o3loww"g:"'t c�rtifyttlat'in"th 'pe—tr armanceef the work for which this permit iS Issued,I shall , <br /> I employ persons subiml to workman's compk!oSatiun laws at C'100trlia:' '� f <br /> s <br /> I hereby certify that I have preparedthis application and that,fhe;work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a rules d regulations of the n J, quin Local Health Distript. <br /> APPLICANT'S 51GNATURE X E y <br /> i <br /> FOR DEPARTMENT USE E.ONLY <br /> j r: . <br /> ' Fee Is Due' 11ANNUAI!LY?- ❑ PER-UNIT�=sr'.El PER SITE„x-. 0_'EACki � January t &Received By•January 31 E] July 1 &Received By July 37 <br /> REMIT <br /> f BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED _. <br /> I AMOUNT <br /> FEE <br /> LESS <br /> t.�. PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER „- - <br /> r'� <br /> Received by Date 'Y Receipt No. - Permit No. Iss ance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITISERVI CES '' 1601 E.HAZELTON AVE.,P.O.Box 2009 STO_CKTON,CA 95201 - '- <br />