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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> `.4:^�' APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is h@rgby made o try on b iness in th jurisdictional area of th Sa Joaquin Local Health istrict <br /> ,F Business Name (DBA).. rr/ �" Address &I*— <br /> aOwner Address <br /> 1 Firm Partners, Addresses and Tel pone Nu bers <br /> IL <br /> Business Telephone No. ` d Emergency Telephone No. <br /> Contractor Licence No. <br /> 4 Applicants Name (Print) / Title - Date <br /> Please check Applicable Category(1-7) and Fill in the Required 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. CAL.-License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> i <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 L cation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Addr s1 oca <br /> AO net Address ` ZI <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑IPACKAGePLANT <br /> PERMANENT E] TEMPORARY 7.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 y' <br /> Plant Location <br /> Plant Capacity No. Units Served r <br /> 7. ❑LAUNDRY For July 1, -June 30, 19 3r <br /> SIZE.' ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals UsedfAmounVMo. ' <br /> Marls ownst or rcansedagent's signah�cerH{iet thefoftowing:`1�ertifX"gar in ing�Q�agce of tltewark far wfalctl this permit fs issued,lshafi trot emptfl;r gn;r r�---� <br /> in such manner as to becone subject to�•rarkrlTan's ca+npensationtaws of Calltorrtla" <br /> Gonna;tar's hiring or aub-cerltracting signature certifies th® fol:owirry: "I certify tltat in the performance df the work for which this perllTi;is issued,l s;lalt r <br /> errlpil�y�erSDr15,:tit►jeC3 Eo worirrtsar s tnmpen&atiun laws of California" <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 r es and regul tions of t n JQaquin Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY - <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT_ ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS ; ` <br /> PENALTY 1 <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issu ce D e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1661 E.FIAZ AYE.,P.O.Box 2009 STOCKTON,CA 95201 <br />