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T Applications Will Be Processed When Submitted Properly Completed.Besure ioatyn rTiC�rr••�••• <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE ocat 7 <br /> Applicati is hereby made o car on bust ess in e'uris ctional area of the SaquiI H�aIYJ� sirvtvic r <br /> F Busines ame (DBA Address `� <br /> z Owner Address <br /> 10 - <br /> a <br /> Firm Partners, Addresses and Tele hone N bers Emergency Telephone No. <br /> CL Business Telephone No. � '� 1 0 <br /> 4 .,� d t;— <br /> Contractor Licence No. Date A <br /> Title } <br /> L Applicants Name (Print) <br /> Please check Applicable Ca ory (1-7)and Fill in th equired Information a} <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License 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 R.S. or R.C.E.No. Y <br /> R.S. or R.C.E. Name <br /> Tesk,LacIon Test Date/Time <br /> 4. 1fH`SANITATION PERMIT <br /> Job Addre /Locatio <br /> Owner - � Address <br /> ❑ SEPTIC TANK [1 CESSPOOL ❑ LEACHING FIELD_P'SEEPAGE PIT PACKAGE PLANT q <br /> 14-REPAIR <br /> 13 OTHER ['ni <br /> M-PERMANENT ❑ TEMPORARY 11 NEW <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 I- <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 Where Certified <br /> Opetator Name <br /> Plant Location <br /> Na. 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 CLEANING, Chemicals Used/Amount/Mo. <br /> Nome owner er licensed agent's signature certifies the following:'9 certify that in the performance of the Ytork for which this permit is issued.I shall not employ arty Payson <br /> in such manner as to become subject to workman's compensAtian laws of California <br /> Conusetw's Hrlog or sub-contracting signature certifies the following: "i certify that in the performance of the work for which this permit is issued,I shall <br /> employ persons sullject to workman's compensation laws of California." <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, d rules an eg ations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEMIT By July 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED F <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> 4 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. is uance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICES 1601 E.HAZELTON AVE.,P.O.Boxl�zc `LSTOCKJ N,CA 4,5201 <br />