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�Q� �f Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> !� C' 1cz APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> -- �� ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> toBusiness Name (DBA) Address <br /> aOwner z� Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 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 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I� <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. A <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. A <br /> Test Location Test Date/Time <br /> (D❑ SANITATION PERMIT <br /> Job Address/Location -1116e, S54 M re,, t rAx' <br /> Owner er' i Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL b<EACHING FIELD ❑ S EPAGE PIT ❑ PACKAGE PLANT p�� <br /> ❑ PERMANENT ❑ TEMPORARY 11 NEW PAIR ❑ OTHER V� <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site r�I <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 /> Home owner or licensed agent's signature certifienthefollowing:"I certify that in the perforritance of the work for which this permit is issued:1 sha!f not e rptoy any persc,'-t <br /> in such manner as to become subject to workman's compensation <br /> laws of California." <br /> Contractor's hiring ortsignature certifies the 70 "1 <br /> ceity that in the jterforrnance o'v ,u01tRpiaypersons subject t„ 4orkma�5 rr for Y,hl f ";: ",r I Shall <br /> colmpcnsati0n laws of Ca!,u n a. <br /> I 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 rules and regulations of the San Joa in Local HeaV District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PERIJNIT ❑ PER SITE ❑EACH ❑ January 1&Received By January 31 n July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 4 4. . <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER <br /> OTHER <br /> Received 15 Date I 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 95261 <br />