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Applications Will Be Processed When Submitted Properly Completed. <br /> APPLICAIA TION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT r <br /> *' LIQUID WASTE ! <br /> 1 I - Address carry on business in the jurisdictional area of the San oaquin Localo <br /> tri <br /> Application.is hereby made to <br /> E I <br /> yBusiness Name (DBA) Va - <br /> z Address <br /> Owner . <br /> c y 1 <br /> J Firm Partners, Addresses and Telephone m rs <br /> Emergency Telephone No.- <br /> aBusiness Telephone No. g y P <br /> Contractor Licence No. _ <br /> Title Date <br /> L Applicants Name (Print) J <br /> Please check Applicable Category (1- )and Fill in the R uired Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30,19 — "Disposal Sites € <br /> Description(Make/Yr., Color) CAL. License Renewal No, <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, _ June 30, 19 <br /> .r <br /> No. of Vehicles{Stored <br /> y <br /> r No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST f ' •^'�' <br /> I R.S. or R.C.E:<Nb. I 'Y <br /> -R.S.or R.C.E. Name <br /> I t Test Date/Time <br /> Test Location 4 I <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location^ <br /> Address , ? ' <br /> Owner ❑`PACKAG ANT C j <br /> C� SEPTIC TANK ❑ CESSPOOL �e LERGHING FIELD REPAISEEPAGE PIT <br /> El OTHER . <br /> ❑ <br /> PERMANENT 13TEMPORARY .NEW <br /> - ' <br /> ;j <br /> 5. 11 CHEMICAL TOILETS For July i,-June 30, i9 <br /> Type Construction M Disposal-Site-- — -- �" <br /> i No. of Units Equipment Storage%Cleaning Locatio6(s).1! <br /> r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June130,19- <br /> Where Certified <br /> Operator Name <br /> t � _ <br /> Plant Location <br /> No. Units Ser�-' <br /> 4 Plant Capacity ved <br /> a <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 /> Horne owner or licensed agent's signature certiftcsthe foltowini"I ccrtlfyth?t in the performance of thswork for whictr this permit is issued,Ij5h <br /> in such manner as to become subiect to �rorf:rrHsn's c�mpensatior;?vim at i�a;ifn ;Iia:" <br /> Contractor's hiring or sub c�ntrec:Enp �laF:@:wre Ger#fics the .oaaw+ny: "I Certify that in the perfarnancc of the work for which ibis employ persons subleci to workrnarrs waipcnsalioiI laws of Ca€ifornia."I hereby certifythat I'have prepared this application and that the work will be done in accordance with San Joaq <br /> ordinances, state laws, and rules and regul nf-4he San oaquin Local Health l]istrict. <br /> APPLICANTS.SiGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due-. ❑ ANNUALLY PE UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By 1 <br /> BILLING REMITTANCE l $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION PATE DATE j REMITTED AMOUNT <br /> FEE <br /> E � <br /> PRORATION d <br /> PLUS y <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receipt No: Permit No. - Issu nee ate Mailed Delivered <br /> Received 6y Dale <br /> 1601 E.ssu neeON AVE.,AYEP.O.Box 2009 STOCKTON,CA 95 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ] <br />