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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 /> LIQUID WASTE <br /> Appiicati s h y made to car.%oneusiness in the jurisdictional area of the San Joaquin Local He l�r' <br /> hBusiness Name (DBA)�1� !P !.>_,4 id Address <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and elephone Numbers <br /> a Business Telephone No. Q Emergency Telephone No. <br /> a <br /> 1 Contractor Licence No. 170 (711\ <br /> L Applicants Name (Print) 0- -�✓� <br /> Title -j Date <br /> Please check Applicable Category (1h) nd it in he equired Informs n 7 <br /> Q� <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) lI` <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) va <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. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address./ILo do <br /> Owner Address <br /> ❑ SEPTIC T ❑ ES OOL ff LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT IZZ <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW PrINEPAIR ❑ OTHER G <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 O <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 /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity 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 /> Home a►vrnrorlielinser' eertift)pfin the performanerof'he vmrkfor which thispermit'is issued,Ishall not employ any person <br /> in Such nicnn ,'aS to <br /> con'-ACtcr'9~:Siei�-� ar Gv:3-. - - .-. - r[st4.:l5. i[:crS f�i!1,1!.:�'..z:�Crtvliifli]{��,f the WOC1C fQr V.'lli%h this rL'i mit IS issued,'.shall t J) <br /> I hereby certify that I have prepared this ap 'cation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,an TrWwIa!6of the San Joaquin Local Health District. n <br /> APPLICANT'S SIGNATURE X (1 , <br /> \T' Q.R.r 0 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE Cl EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DAMOUNT DUE CHECKED <br /> ATE DATE REMITTED <br /> AMOUNT <br /> O <br /> FEE 5 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. IsAuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95201 <br />