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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> *% (For Non-Transferable;Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH.PERMIT SEPTAGE <br /> LIQUID WAW <br /> Application is ereby made to car on basin intheJuriscifc Tonal area.of the San Joaquin Local Health Distric <br /> F)Business Name (D ) s <br /> z Owner Address•• <br /> a Address <br /> J Firm Partners, Addresses an Telephone Numbers <br /> ILBusiness Telephone No. <br /> Contractor Licence No. <br /> Emergency Telephone No. <br /> � - - <br /> LApplicants Name (Print) ' Title <br /> Pilease check:,Applicatile CPqqry���ReDate <br /> (1-7) and Fip.in.thequired l ormation <br /> 1, ❑_PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) .. <br /> For July 1, . June`30, 1g-' - - ,.;_:Disposal Sites- _ q <br /> Description.(Make/Yr-,.Color) I <br /> Serial No. <br /> CaiJ ilyt_"'J­ ; CAL. License No. CAL. License Renewal No. <br /> t .Gal., Weights & Measures No. <br /> Equipment Parking Address 4'.t .s! a <br /> 2. ❑(PUMPER YXRD` <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 s�' <br /> _ R.S. or R.C.E. No. <br /> Test Loca ' Test Date/Time �+ <br /> 4• ANITATION PER T <br /> dr /Loca 'on <br /> k <br /> e r <br /> Address <br /> SEPTIC T K ❑ CESSPOOL EACHING FIELD ,SEE PAGE-AT ❑ PA AGE PLANT V <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW LF�EpAIR "" f ❑ O7HER <br /> 1r <br /> 5. ❑ CHEMICAL TOILETS For July ,1_June 30 `19 moi^' <br /> Type Construction . 'IFr <br /> Disposal Site06 <br /> No. of Units Equipment Storage/Cleaning Location(s) I <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30,119 <br /> Operator Name <br /> Plant Location I <br /> Where Certified <br /> Plant Capacity No. Units Served ,k e <br /> 7.' ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq' Ft. <br /> ❑ DY CLEANING, Chemicals Used/Amount/Mo. <br /> omeewnerw6eensed - - <br /> insuchmannerasta ag 2alonletscertHiestAsfallewinp:"Icertiiiy�rthatinfha r <br /> bel mesubI t0 workman's compensation laws of CafiTarnia" rmar►cepifhearwktprw[ltehthispermitisissued,ishall notem to a <br /> Contractor's hiring ar aub-ca+traciing sig�atnre ee.-Pities the #�1fo?rof that <br /> � P y "person " <br /> employ Dersans subject in workman's c0 n9: . ,.In,flR per;orm,noj;o',j,,"work fur wh•Itfi this permit Is issued,I shalt <br /> . 1npel;sation.iaw,.of.Caiilar <br /> I hereby certify that'I have prepared this application and that the work Ovill be done in accordance w" <br /> ordinances, state laws,grid rules and regulation's o th San Joaquin Local'H}alth District. with San Joaquin County <br /> APPLICANT'S SIGNATURE X -' <br /> r FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACHF <br /> _ ❑ Jarivary d`8,Received By January 31 ❑ July 1 &Received BY July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> L" DATE DATE ".1 REMITTED AMOUNT DUE CHECKED <br /> FEE <br /> AMOUNT I <br /> � (�� � <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> M <br />- OTHER .ry <br /> OTHER <br /> Received.by <br /> Receipt No. Permit No- ISS nce Date <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />