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Applications Will Be Processed When Submitted Properly Completed. BeSureTosign 1nAppnuauvrr <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is h eby made to c rry n busi ess in the juris ctional area of the San Jo a uin Local Health Distric <br /> Business Name A) Address <br /> v, G -- — <br /> aOwner Add ess <br /> u Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. w �f O� Emergency Telephone No. <br /> Contractor Licence No. 32 ? Z` A— 2 3 z� o� <br /> LApplicants Name (Print) R e —'— Title l/ - Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information f k <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) �} <br /> For July 1, June 30, 19 ` Disposal.Sites <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. No. <br /> R.S.or R.C.E. Name <br /> Test_Lotion Test Date/Time <br /> q. Ltt'SANITATION PERMIT <br /> Job Address/Location ~r <br /> O_,w�r Address <br /> Lfd SEPTIC TANK ❑ CESSPOOL CHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> El PERMANENT 11-TEMPORARY NEW ❑ REPAIR 1:1 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 1 <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 /> Where Certified <br /> Operator Name <br /> Plant Location <br /> PNo. 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/Arnount/Mo. <br /> Rome owner or licensed agent's signature certifies the fallowing:"1 certify that irlthe performance of the work for which this permit is issued,t shall not emptoy any person <br /> in such manner as to become subject to workman's compensation laws of Calitcraia', <br /> contractor's hiring or sub-contracting signature certifies the fOtlowirrg: "t certify that in the performance Of the work for which this permit is issued,I shall <br /> employ persons subject 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, and ruleand regulations 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 &Received <br /> By <br /> 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS V <br /> PRORATION <br /> PLUS Lf <br /> PENALTY J� <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. lissuanceluate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 85201 <br />