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Applicatlons Will Be Processed When Submitted Property Completed.Be Sure To Sign TheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT i <br /> -� LIQUID WASTE <br /> Applicatio is hereb ad to carryy u s in the jurisdictional area of the San JoagW Local altfi D' trick, <br /> Address �,j— <br /> rBusiness (1A) Address <br /> a Owner <br /> 0 Firm Partners, Addresses and Telephone Numbers, <br /> i `� Emergency Telephone No. �� f. <br /> IL <br /> Business Telephone Noy�rw . w <br /> Contractor Licence No. 34 <br /> ` Title B C�}.c� Date <br /> LApplicants Name (Print) <br /> Please check Applicable Category and Fili'in the Required,Information .. n rr:= �, � taL,l'�u `=. 'F �J <br /> (1-7) <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30,19 - Disposal Sites' <br /> K <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> I <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 t <br /> 3. ❑ PERCOLATION TEST R.S.or R.C.E. Na. <br /> I <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4. 0"rANITATION PER ITi r ! Q� <br /> Job Address/ ation r �`"~� <br /> Address <br /> Owner <br /> 11-SEPTIC TANK ❑.CESS POOL 5�<EACHING FIELD B--SEEPAGE PIT ❑ PACKAGE PLANT <br /> ������ ❑ ❑ EDOTHER il <br /> I.�PERMANENT TEMPORARY �W REPAIR 1_ { <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 w <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 /> Operator Name <br />( Plant Location ` <br /> Plant Capacity i` 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 /> r Rome owneror IlCensed agent's. cer!ifiesthe#nppwing:"I Gerti fop th at.in the performance of the work for which this perrnit is 1880d,l Shell not Ompley Arty p+lfeon <br /> F in such manner as to become, workman's compznsat=on:atiYs�f e, li°vrnta.' <br /> Contractor's hiring or <br /> 5tsn-eor-:rsctin 't_r-;i;r• cprcr:'r '<.Iov�itll: "1 CE)aiiy thd!4n!h0 p©rfOrillaRC©Of(il0 Work for which this Qermit i5issued,1 Shed <br /> employ persons subject 1:,svcr ,i1 i"r,'S crr,,G'�siiar,le:a ti�s'ur;.la.' <br /> I hereby certify that I have 'prepared this application ed that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an nd re lotions oft J uin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> • r <br /> FOR DEPARTMENT USE ONLY ' <br /> Fee IS Due: 13 ANNUALLY ❑ PER'UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &ReceivedJuly 31 <br /> REMIT <br /> I BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> P <br /> FEE <br /> LESS I <br /> -PRORATION <br /> PLUS - <br /> PENALTY - <br /> OTHER <br /> OTHER s <br /> Receipt No. Permit No. I suanc Date Mailed Delivered, <br /> Received by Date 1801 E.HAZELTON AVE.,P.Q.Box 21109 STQCKTON,CA 952 1 , <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL'HEALTH PERMIT/SERVICES , ` }�D'� <br />