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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> `APPLICATION <br /> Y (For Non-Transferable,Revocable,and Suspendable) / SEPTAGE <br /> {`o ENVIRONMENTAL HEALTH PERMIT f <br /> . LIQUID WASTE <br /> ApplicattO is�hiierr��q made to on b mess in the jurisdictional area of the San Joaquin a Healt i trict <br /> y <br /> Business. ame (DBA) N�+k Al IS► Aft A <br /> Ad res <br /> i Owner A-)OJ Address <br /> J Firm Partners, Addresses a8 TelephCone Num ers <br /> aBusiness Telephone No. � . Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) �(1C� Titie Date �, L"" <br /> Please check Applicable Category(1-7)and Fill in the Required information I <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) j <br /> For July 1, June 30, 19 Disposal Sites f" <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 <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 /> Tet L cation Test Date/Time <br /> 4. SANITATION PER <br /> Job Address/Location <br /> Owner Address <br /> 11 SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 1:1TEMPORARY 11NEW ❑ REPAIR XOTHEii �gr`oe.(.}TF live— 1ivS'N}_t_ <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30; 19 \d0 \ <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 /> Horns owner or licensed agaWationatureowttt&O"wfoltowing:"I certifythatirtMe perfomtanceof theworktio which this permit is issued,i shall not errp!ry any person <br /> in such manner as to become subject to wrorkman s compensatiol:law;of Calftl flia. <br /> contractor's hiring or sub-contracting signature certifies the fotbwing: ­I certify that in this performance of the work for which this pert It Is Issued,I shall <br /> employ persons subject to workman's compensation 1 California:' <br /> I hereby certify that I have pr sap nd that the work will be done in accordance with S n Joaq1{i1:1 Count <br /> ordinances,state laws,an s re I the ealth District. G <br />*APPLICANT'S SIGNATURE X ec 5, <br /> 6 <br /> FOR DEPARTMENT US LY <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 AMOlft3T DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE o <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by tDate 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 />