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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign Tne Apprlcanon. <br />APPLICATION <br />-- (For Non -Transferable, Revocable, and Suspendable) SEPTAGE <br />ENVIRONMENTAL HEALTH PERMIT <br />I.IQUIo WASTE <br />Appiicatio is hreby made to rry on bus'ness In the jurisdictional area of the San Joa uin Loca alt istrict L f` <br />cn Business Name (DBA) /1% i Address. f7l�'�7 <br />Owner .; ,. C .. - Adds g , <br />Firm Partners, Addresses and Telephone Numbers , <br />a Business Telephone No. ►•-• Emergency Telephone No: <br />a <br />Contractor Licence No. y , <br />Applicants Name (Print) /� ~� - % 17� Title <br />Please check Applicable Category (1-7) and Fill in the Required Informatlon.,r, <br />1. ❑ PUMPER VEHICLE PERMIT' REGISTRATION (FOR EACH VEHICLE) <br />For July 1, June 30, 19 = - wDisposal 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 Stor <br />2�pig <br />3. PERCOLATION TE <br />R.S. or R.C.E, Name D 'A.$. or R.C.E. No./ � <br />Test Location *� t.— Test Date/Time <br />4 ❑ SANITATION PERMIT �e S <br />Job Address/Location <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 <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 />Homo owner of licensed agent's signature cortifie9 ihn fo(fewinp; "I Certlfy that In Ih s perfc rm ance of thework for vihich this permit is issued, I shall not employ any person <br />in such manner as lo become subject to workman's ccrnpensation 16.vs of Calikorrila <br />o -n- + I yes ct=i ?'•;ir w:r r, ;i;y+l at.i s i:tc prrl:3rmanr !e a` ihi workAorwilich tilts permit is issued, l Shalt <br />Contraotor's •hir.nr� r spat: r. ralain3 r. tse_ r ^: _. <br />employ persons sUCj ct to lYJriCG'i ;; $ CuT ?iSB:!q'i <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, and_,F9lesA9d regul�'..ons of the San Paquin Local Health District. <br />APPLICANT'S SIGNATURE X <br />FOR DEPARTMENT USE ONLY <br />eee Io n..e• i`7 ❑ Pca I IALT ❑ PER RITE ❑ EACH - ❑,January 1 & Recelved 6y January 31 ❑ July 1 & Received By July 31 <br />APPLICANT—RETURN ALL COPIES TO: <br />Receipt No: f Permit No. <br />ENVIRONMENTAL HEALTH PERM IT <br />fiffA WITIN1�1` R <br />1601 E, HAZELTO AVE., P.O. Box 2009 STOCKTON, CA 95201 <br />i <br />REMIT <br />BASE <br />EXPLANATION BILLING * <br />REMITTANCE i AMOUNT DUE <br />CHECKED <br />DATE <br />DATE REMITTED <br />AMOUNT <br />FEE <br />LESS <br />fS <br />PRORATION <br />— <br />(S " <br />PLUS <br />} <br />PENALTY <br />OTHER <br />OTHER <br />I - <br />APPLICANT—RETURN ALL COPIES TO: <br />Receipt No: f Permit No. <br />ENVIRONMENTAL HEALTH PERM IT <br />fiffA WITIN1�1` R <br />1601 E, HAZELTO AVE., P.O. Box 2009 STOCKTON, CA 95201 <br />