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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 /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application 's hereby made to carry on business in the jurisdictional area of the San Joaquin.Local Health District <br /> •Business Name DBA .4 I�� �' Z� <br /> y (DBA) Address �•. <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> 0. Business Telephone No. 6 O Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) . r Title Date <br /> Please check Applicable Category(1-7) and Fill in the Required In ormation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) a <br /> For July 1, - June 30, 19 - - 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 /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time I <br /> 4. A SANITATION PERMIT <br /> Job Address/Location <br /> t7 I <br /> Owner = Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 ` T <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 I <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> }tome ownererNeensed agert'E slanalurB G£rtifleS the following:"I cert's`yy that in the perfcrmarce of the work fnr which this permit is issued,I shall not employ aJ <br /> In such manner as to teca.ME subject to work la^'s campene,ti^is!:,t�al�:,lir`errs;. <br /> Contractor.lr hinn or 6u6-cnnt•.aetinp sign-lure cer±;ia •,".:r. &.0iolt ng: " CEr <br /> I tity that in the performance of the work to which this permit is issued,i shall <br /> employ persons sutllect to workman's compensation caws of Czliiorr,ia:' <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 4 <br /> ordinances, state laws, ;�nd , �and �ula 'on�ole�Sanoa�lncal H <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &ReceivedByJanuary 31 ❑'July 1 &Received By July 31 <br /> _ P REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUEti• r CHECKED <br /> Y DATE DATE REMITTED `'i.AMOUNT <br /> FEEJ."D ' <br /> LESS J <br /> PRORATION V I <br /> �!w <br /> PLUS <br /> .PENALTY - - <br /> OTHER I <br /> OTHER <br /> Received by Date Receipt No. Permit No j Issuu~nce,Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES Tp: ENVIRONMENTAL HEALTH PERMIT/SERVICES L. `1601 E.HAZELTON AVE.,P.D.Box 2009- STOCKTON,'CA 95201 <br />