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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 f <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> r LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rBusiness Name (DBA) Address <br /> aOwner U O Address# t' t <br /> Firm Partners, Addresses and Telephone Numbers ..r <br /> aBusiness Telephone No. Emergency Telephone No.w , <br /> Contractor Licence No. ± <br /> 4 Applicants Name (Print) o Title Date h <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 /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored i <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. d <br /> Test ocation Test Date/Time <br /> 4, SANITATION PERMIT <br /> Job Address/Location b t <br /> Owner Addresses Q -V <br /> SEPTIC TANK- ❑ CESSPOOL , +LEACHING FIELD ❑ SEEPAGE PIT 613 PACKAGE PLANT t J <br /> ❑ PERMANENT ❑ TEMPORARY [ANEW F 'ti, �, �"❑`REPAIR ❑ OTHER /6700p k <br /> S. ❑ 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 Certifiedi- t <br /> Plant Location C k <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 owner orticensed agent's signature c4"ftfiestha fallovAng-."I certffy ThM In the performance ntihe work.for which this permit is issued,I shall wit employ any person 1. <br /> in such manner as to became subject to Norhmaa'�comonsaVo,i Saws oft,ii;ami, - <br /> Contraetor's hiring or sub-contracting signature certiRec ilia sunowins; "f certify'Mai in the performance of ii u work for which ibis permit is issl ed,I shall (�y <br /> employ persons subiect to we, man's compwisatlon laws of Caiif3rnia." <br /> I hereby certify that I have pr ared this applicat' n and hat"t work will be done in accordance with San Joaquin County <br /> ordinances, state la d r es and regulatio Of the S Jo in Lo H h District. <br /> ,.- <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE O <br /> Fee Is Due: ❑ ANNLLALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> Al Iu' lei D <br /> FEE <br /> t LESS - <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -Received by - D to - Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL'HEALTH PERMIT/SERVICES "1601 E.HAZELTON AVE.,P.O:Sox 2009 STOCKTON,CA 952D1 <br />