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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) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> .0 f LIQUID WASTE <br /> Application i ereby made t carry on b sines.s in the jurisdictional area of the Sa oa Local Health Distri <br /> rn Business Nam DBA) ,� ;Address 7 <br /> aOwner Address 4 7. <br /> Firm Partners,Addresses and Telephone Numbers <br /> 4 Business Telephone No. j O j. Emergency Telephone No. <br /> j Contractor Licence No. _ <br /> L Applicants Name (Print) Title Da�te� <br /> Please check Applicable Cat ory (1-7) and FIII in th equired Information <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. i CAL. License No. CAL. License Renewal No. <br /> CapacityGal ,Weights & Measures No. <br /> Equipment Parking Address <br /> •` I <br /> 2. ❑ PUMPER YARD f <br /> s <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored r <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST i <br /> R.S. or R.C.E. Name R.S.or R.C.E.No. # <br /> Test LL ation Test Date/Time )_ i <br /> 4. LrJ SANITATION PERMIT <br /> Job Address ocatio <br /> Owner Address # <br /> ❑ SEPTIC TANK ❑ CESSPOOL t ❑ LEACHING FIELD D-9—EEPAGE PIT El Pk61KAGE PLANT <br /> ,,.�,, �� ❑ OTHER �e-4-4 / <br /> ❑ PERMANENT ❑ TEMPORARY C1 NEW 0,<P-AIR • <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> e � <br /> Type Construction' Disposal Site_ <br /> C <br /> No. of Units Equipment Storage/Cleaning Location(s) t <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Servyed <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 - .1, <br /> SIZE 13 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft_ 1 t <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Homet•wfterorY�tenaedagertt's ataracertifstAefotlowl,r$:"Icertifyfhatinthepertormattcepfthework fnrwltict►thispermttisissueC,iShatlnatem io a <br /> in such manner as#;Cecnrrte;uujeCf to►vor;;,nan's compensation iavrs of California." <br /> -ooI P Y by pusort <br /> Contractor's fairing of sa6ntractiog.signature certi�fees the following; '1 certify t:zat in the per#ormance of the work for which this perm ,it is issued,I hall <br /> employ persons subject to workman's crmpeasation laws of Calilornia.- <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, an ules and re tlo of the San Joaquin Local Health District. _ <br /> i <br /> 'APPLICANT'S SIGNATURE X <br /> i ` ` _ " " -^� !` • ' FOR DEPARTMENT USE ONLY <br /> 1 - - - _ _.l '-- <br /> 4=Fee es Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Janyuary 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE <br /> BASE EXPLANATION AMOUNT DUE CHECKED �{1 <br /> r- DATE DATE REMITTED AMOUNT �v\ <br /> FEE - <br /> LESS } �" <br /> PRORATION <br /> L <br /> PLUS <br /> PENALTY _ # <br /> OTHER <br /> i-: <br /> OTHER <br /> Received by Date Receipt No. Permit No, ' Issua ce Date Mailed D6livered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> r � b� -T,-A q/16/6ti <br />