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plical-lots Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Nan-Transferable;Revocable,and Suspendable) , SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio is here ma o carry on business in.the.jurisd'c_tional area of the San Joaquin Local Health District: t .� <br /> NBusiness Name (DBA) Y �Address <br /> z Owner Address <br /> Firm Partners, Addresses and Telephone Nu ers <br /> aBusiness Telephone No. _ .._. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title " W u�ry Date rt 4 <br /> Please check Applicable Category (1-7)and Fill-in the Required Information '.% . MYw, �.� ., •3w 3 ;,.r ., <br /> 1. ❑ PUMPER VEHICLE PERMT REGISTRATION(FOR EACH VEHICLE) V ' <br /> For July 1, = June 30, 19. -" _ `Disposal Sites 7 - v 1 <br /> Description(Make/Yr., Color) — <br /> Serial No. 'CAL. License Na. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD iJjJ <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 /> Test Location �M Test Date/Time <br /> 4. ❑ SANITATION PERMI L{ <br /> Job Address/Locati nF. <br /> Owner <br /> AN Oil Address <br /> SEPTIC TANK ❑ CESS 160L LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. 11 CHEMICAL TOILETS Fo``r July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Ip Equipment Storage/Cleaning Location(s) <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 i S <br /> Operator Name Where Certified. c-}} <br /> Plant Location _ <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For•July 1, June 30, 19 <br /> SIZE: C3Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq- Ft. a t s <br /> Q Y L.2,ING, Chemicals Used/Amount/Mo.` <br /> a w nor lcensedegent'ss natyrexerl;festhe#otlrHnng.'?certifgy4hatintheperformanceofitteworkfo�whichthispermitisissued,Ishallnotemployanyperson <br /> in such manner as to become subject 0 workmates 1:ur pensation favrs of Caii,orllta-' t <br /> Contraetpr'a hiring or sub-con.rsignature certifies the fotlovying. 1 Celtity that in the performance of the%,ork for whicit this permit is issued,I shall <br /> employ persons subject to lvorkmarl's Cempensatror,taws of C:al:fornia." , <br /> I hereby certify tFiat I have prepared s applic tion a hat the work will be done in accordance with San Joaquin-County— <br /> ordinances state e_laws, and rules an' egul soft n Joaquin Local Health Dk istrict. /y <br /> S APPLICANT'S SIGNATUIRE X III�1�t <br /> t 41 <br /> i -- -FOR DEPARTMENT.-USE-ONL-Y <br /> Fee Is Due: ❑ ANNUALLY., ❑ PER UN11ka.; -� ❑-PER SITE�" ❑.EACH -❑ January-1-&Received By January 37 ❑ July 1 &Received By Su4y,31 <br /> F F t 4 / RMi <br /> II' ,f9ILLING REMITTANCE {iii MOUNT DUE-f' CHECKED <br /> BASE EXPLANATION DATE ""^"^°"DATE '---- tREMITTEO""""'" s ;---AMOUNT` <br /> �iI '- - . <br /> 4S <br /> PEE <br /> LESS r <br /> IN <br /> �. <br /> PLUS <br /> --�—PENALTY ^ - -^--t-- <br /> t OTHER <br /> OTHER <br /> Received by Date !Receipt No. g Permit No I uanc Dae Mailed Delivered <br /> APPLICANT—RETURN ALL CrOPIE5 TO: ENVIiiONMENTAL HEALTH PEAMITISERVICEs 1601 E.14AZELTON AYE„P.O.Box 2009 STOCKTON,CA 95201 <br />