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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. <br /> f APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatjon is hereby mad car o busin�[ss i he jurisditional area of the,14n q uin Local HeaLlh District <br /> y Busines Name (DBA) <br /> I- Owner �- Address <br /> d <br /> J Firm Partners, Addresses I pho a Num ers <br /> IL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. S <br /> r- �r <br /> Applicants Name (Print)-' - - Title Date <br />- Please check Applicable Category (1-7)and Fill In the Required Information <br /> C 1.J0 PUMPER VEHICLE PERMIT,REGISTRATION (FOR EACH VEHICLE) �J <br /> For July 1, _ June 30, 19 Disposal Sites t <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> -CapacityGak,•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 IL <br /> R.S.6 R.C.E. Name r R.S. or R.C.E. No. <br /> Test Location ' Test Date/Time <br /> i <br /> A. ❑ SANITATION PERMIT t t O S <br /> Job Add ss/Locution [ I <br /> Owner U�-- Address <br /> 11SEPTIC TANK 11CESSPOOL EACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11 PERMANENT 1:1 TEMPORARY ❑ NEW REPAIR ❑ OTHER n <br /> 5. 0 CHEMICAL TOILETS For July 1,-June 30, 19 ' �•J <br /> Type Construction --- a--_y Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) i <br /> 6. PACKAGE TREATMENT PLANT For July'l', June 34, 19 <br /> Operator Name Where Certified <br /> t f <br /> Plant Location i <br /> Plant Capacity No. Units Served Ishall ..7. 0 LAUNDRY For July 1, -June 30, 19SIZE: ❑ Less Thari,1,o00 Sq. Ft., -❑ Mofe Than 1,000 Sq. Ft. <br /> DRY CLEANING, Chemicals Used/Amount/Ivlo. fHomeownewiicerisedagent%signaturecertifiesthefoilovArrg:"I certifythatiotheperformanceoftheworkforv;hichthispermitIsIssued,IshalInotempin such manner as to become subject to.ti�orklnaris campersatien laims of California.' }Consraetor's hiring or sub-conuacting cidmiture certifies)the toliowirrg: -1 certify that iii the performanceof the work for which this permit is issuemploy persons subject to workmans compenstion laws of Cali{1 uia." <br /> I hereby certify that I ave pre tied his plication and th the`work will be done`-in accordance with San Joaquin Coun <br /> ordinanc , state d rules r1d egut tl ns oft a Sa i quip Lo I Health District. I r <br /> ! ( i r <br /> APPLICANT'S SIGNATUR <br /> ( FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE © EACH ❑ January 1 &Received BytJanuary 31 ❑ July 1 &Received By July 31 <br /> s REMIT <br /> BASE EXPLANATION BILLING REMITTANCE s AMOUNT DUE CHECKED `. <br /> DATE DATE REMITTED AMOUNT <br /> I FEE S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY J O <br /> OTHER <br /> ! OTHER . ..►- �� ..�._ _ -.- _, �� ; <br /> i <br /> k Received b Date Receipt O. Permit No, ssua a Date Mailed Delivered <br /> L APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1 Wt E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> t <br />