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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 c <br /> ` ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl!cation is hereby made to carry on business in the jurisdictional area of the San Joaquin.Local Health District <br /> Co-Business Name(DBA) 45 4, <br /> z Owner Address j <br /> J Firm Partners, Addresses and Telephone Numbers Y � <br /> aBusiness Telephone No. Emergency Telephone No.. <br /> Contractor Licence No. <br /> Applicants Name (Print) jL '� & Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information w <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites - <br /> D_escription(Make/Yr., Color) _ <br /> Serial No. y y w CAL. License No. �_ CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. I '" <br /> Equipment Parking Address r <br /> 2. ❑ PUMPER YARD I <br /> For July 1, June 30, 19 } <br /> No. of Vehicles Stored t_ <br /> No. of Chemical Toilets Stored t 4 <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 <br /> 4. rK SANITATION PERMIT f <br /> Job Address/Location 3d• 6 A p AV4 San e—len- / - - <br /> Owner I2-4kP, C44 IZ72-2--C2 Address_ 9!5- <br /> .11 SEPTIC TANK ❑ CESSPOOL.ti LEACHING FIELD , SEEPAGE PIT - ❑ PACKAGE PLANT !_ <br /> ❑ <br /> PERMANENT ❑ TEMPORARY e•9NEW REPAIR C1OTHER_ <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 ` F <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity is No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 t <br /> SIZE: ❑ Less Tham.1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. '"t <br /> Homeownerorlieemwdeg®nt'ssignattirecert'Vosthctottowinut "]cartiNihat€n the pet•tormanceofthe nrorkfarwMOttisPc,unitisiss.�e`w,lsha ,te <br /> :lnmployany person <br /> in such manner as to become suhjoct is vrot<a an's crsmpensatien i$vJ5 tri <br /> i Contractor's t;rFne or ,ate-contvactin;; s,9nRturc ^.crttioa thJ iotlowtn$: "i certify that in the periarman�s of-',he wark for Fvhich tiffs ,a <br /> e lt is issued,!s;all <br /> r employ persons subject to workman's compesisation laws of California." - <br /> f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaq County <br /> ordinances, state laws, and rules and regulations of the Sa oaquin Local Health District.� <br /> APPLICANT'S SIGNATURE X <br /> JQ <br /> r FOR DEPARTMENT US ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT. ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> RILIrING REMITTANCE ATTED <br /> REMIT <br /> BASE EXPLANATION DATE DATE AMOUNT DUE CHECKED <br /> 1 AMOUNT <br /> FEE 74 <br /> LESS <br /> PRORATION T <br /> PLUS <br /> PENALTY w <br /> OTHER <br /> OTHER <br /> _ En 7 <br /> Z � <br /> Received by Date Receipt No. - -Permit No. Assuancp Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES- 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201' - <br />