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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> L <br /> APPLICATION <br /> s (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> a. <br /> Application is hereby made to car on busin s in th j risdictional area of the San J uln Local Wealth District <br /> ,n Business Name (DBA) Address � � ��f?li -! <br /> i Owner Address <br /> a <br /> J Firm Partners, Addresses a T e hone Numb rs <br /> aBusiness Telephone No. Emergency Telephone No, <br /> Contractor Licence No. <br /> Applicants Name (Print)�� Y �LL� L� l-� Title Date—77 <br /> Please check Applicable Category(1-7)and Fill in the Required Information p <br /> 1."❑,PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For'July 1, f June 30, 1�9 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 /> 1-0 TEST <br /> R.S.;or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time 7 ' <br /> 4. ❑ SANITATION PER lO <br /> Job Address/Loc tion <br /> O ner _ Address <br /> SEPTIC TANK�# ❑ CESSPOOL° CACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY MKIEW ; REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, - une 30, 19 { <br /> Type Construction ` f Disposal Site r <br /> No.of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 t <br /> r <br /> OpeI rator Name - <br /> Where Certified <br /> Plant Location v } r <br /> Plant Capacity No. Units Served <br /> 1 <br /> 7. 11 LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRAy CLEANING Chem cats lJsed/Amount/Mo. <br /> ! ome ownarorlleenss�agent S Sigraturo cPrtMerthe followimg:"I ccr?lfy that in lfle performance of'he woA for which this permit is issued,Ishall not employ any pers- <br /> im such manner.as to becom:,sebject:,:s:or4;nan's cnm,,BnSati-on laws cf Ca.iforn'a <br /> Contra:tor's hiring P*r auh-Pelt. ctlag r6t;:�he�r�.-c r,:,;cF� Cie fu;;owmg: "I certify that iz the performance of the work for which this permit is issued,l shall <br /> employ persons subjedt to.workman's°conpens3tlsn laws ul Cal;,;,r.,:a." ; <br /> hereby c I t I have prepare is applicatio d that the work will be done in accordance with San Joaquin County <br /> ordinances, laws, rut a re ulat' s f t e ari J ui ocal Health District. <br /> e <br /> APPLICANT'S SIGNATURE X <br /> f Y + <br /> I <br /> ,FOR DEPARTMENT,USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE O tACH -'C January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ✓ REMIT <br /> i BASE EXPLANATION+ BILLING'S REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMO T n <br /> FEE <br /> Y LESS <br /> !, PRORATION - � <br /> t <br /> PLUS J <br /> I PENALTY V f <br /> a <br /> OTHER r <br /> OTHER = <br /> I <br /> Received by 0 Date Receipt No. Permit No. Issuan at Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEL E.,P.O.Box 2009 STOCKTON,CA 95201 { <br />